The Impact of Depression during COVID-19 on Suicidal Ideation in Adolescents: Anxiety as a Mediator and Loneliness as a Moderator

The Impact of Depression during COVID-19 on Suicidal Ideation in Adolescents: Anxiety as a Mediator and Loneliness as a Moderator | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Impact of Depression during COVID-19 on Suicidal Ideation in Adolescents: Anxiety as a Mediator and Loneliness as a Moderator Eun-Joo Choi, Yun-Jung Choi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9343756/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background This study investigated the mediating effect of anxiety and the moderating effect of loneliness on the relationship between depression during the coronavirus disease 2019 (COVID-19) pandemic and suicidal ideation among adolescents. Methods Data were analysed from the 17th Korea Youth Risk Behavior Web-based Survey (KYRBS), a 2020 self-report survey targeting 54,848 middle and high school students in South Korea during the COVID-19 lockdown. Results Depression had a significant direct effect on suicidal ideation and an indirect effect mediated by anxiety (B = 1.28, p<.001; Sobel test Z = 36.91, p<.001). A one-unit increase in depression raised the likelihood of suicidal ideation by 2.64 times (Odds Ratio [OR] = 2.64, 95% CI: 2.486–2.811), while anxiety increased the possibility by 3.31 times (OR = 3.31, 95% CI: 3.166–3.460). Loneliness significantly moderated the relationship between anxiety and suicidal ideation, with a one-unit increase in loneliness raising the odds by 4.22 times (OR = 4.22, 95% CI: 4.051–4.219). The interaction between anxiety and loneliness amplified the possibility by 1.68 times (OR = 1.68, 95% CI: 1.654–1.679). Conclusions These findings highlight the intricate interplay between depression, anxiety, and loneliness in influencing suicidal ideation among adolescents during the COVID-19 pandemic. Loneliness emerged as a critical factor moderating the relationship between anxiety and suicidal ideation. Early identification of anxiety and interventions aimed at alleviating loneliness as integral components of adolescent suicide prevention strategies, particularly during societal crises. Comprehensive intervention programs addressing these interconnected factors psychological factors are essential for improving adolescent mental health outcomes. Health sciences/Diseases Health sciences/Health care Biological sciences/Psychology Social science/Psychology Health sciences/Risk factors Adolescence Anxiety Depression Loneliness Suicide Figures Figure 1 Figure 2 Figure 3 1. Introduction Adolescent suicide rates are a critical global social issue that has increased significantly following the coronavirus disease 2019 (COVID-19) pandemic. Notably, during the early stages of the pandemic in 2020, while general suicide rates in countries such as the United States, Japan, and South Korea declined compared to those in 2019, adolescent suicide rates increased by 9%. This trend highlights adolescent suicide as an urgent public health and societal challenge requiring immediate attention (Ministry of Health and Welfare 2022 ; Bridge et al. 2023 ; Fushimi 2023 ). Adolescence is characterised by rapid biological and emotional changes that make individuals particularly vulnerable to mental health issues. Psychological traits, such as experiential avoidance, during this stage are associated with an increased risk of developing psychosocial disorders (Theberath et al. 2022). Conditions such as anxiety, depression, and phobias are highly prevalent among adolescents, further underscoring their susceptibility to mental health vulnerabilities (Costello et al. 2011 ). When left unaddressed, these mental health problems can have negative long-term consequences on adolescents’ quality of life and functioning, extending into adulthood. The coronavirus disease (COVID-19) pandemic has exacerbated mental health crises among adolescents (Wiederhold 2022 ). Public health measures implemented to mitigate viral transmission, such as school closures, restrictions on outdoor activities, and social isolation, have disrupted daily routines and contributed to psychological distress (Samji et al. 2022 ). Studies indicate that the prevalence of anxiety and depression among adolescents has risen significantly during the pandemic compared to pre-pandemic levels (Racine et al. 2021 ; Samji et al. 2022 ; Theberath et al. 2022). Depression and anxiety are the major predictors of mental disorders and suicidal ideation among adolescents (Schnitzer et al. 2023 ). Wang et al. ( 2022 ) found that the prevalence of depression and anxiety peaked during the later stages of pandemic-related restrictions, and longer lockdowns further exacerbated these issues. Adolescent suicide is widely known to be influenced by various mental health and life stress factors. However, during the pandemic, social isolation due to school closures and home confinement have emerged as key factors contributing to adolescent suicide. The pandemic has disrupted social support systems and mental health services, amplifying suicide risk (Schnitzer et al. 2023 ). While the pandemic has highlighted the interplay among depression, anxiety, and social isolation, comprehensive studies examining their combined impact on suicidal ideation remain limited. Research conducted during the lockdown period has revealed that adolescents experience severe loneliness due to restricted social interactions, identifying loneliness as a significant stressor (Cooper et al. 2021 ; Al Omari et al. 2023 ). Social isolation affects younger individuals more adversely (Alam et al. 2023 ). Although adolescent use of social media and online interactions increased during the pandemic, these virtual connections were not perceived as adequate substitutes for in-person interactions (Asscheman et al. 2021 ). Existing studies demonstrate strong correlations between loneliness, depression, and anxiety, with these variables mutually influencing each other (Gadassi Polack et al. 2021 ; Barbieri & Mercado 2022 ; Al Omari et al. 2023 ; Cena et al. 2023 ). Adolescents reporting higher levels of loneliness were four times more likely to experience suicidal ideation, emphasising the importance of addressing loneliness as a strategy for suicide prevention (Macalli et al. 2022 ). While this study confirmed the significant roles of depression, anxiety, and loneliness in influencing suicidal ideation among adolescents during the pandemic, it sought to fill this gap by understanding the interactive mechanisms among these factors. Therefore, this study proposes the following hypotheses (Fig. 1 ): COVID-19-related depression affects suicidal ideation directly and indirectly through anxiety as a mediator. Loneliness moderates the relationship between anxiety and suicidal ideation. The indirect effect of COVID-19-related depression on suicidal ideation, mediated by anxiety, differs by levels of loneliness. [Insert Fig. 1 here] This study aimed to elucidate the complex interplay between depression, anxiety, and loneliness in influencing suicidal ideation during the COVID-19 pandemic. The study sought to uncover the interactive mechanisms of adolescent mental health by integrating the mediating role of anxiety and the moderating role of loneliness. The findings of this study are expected to provide practical insights into suicide prevention and mental health promotion during social crises and offer actionable guidelines for public health and mental health management practices. 2. Method 2.1. Research Design This study used data from the 17th Korea Youth Risk Behavior Web-based Survey (KYRBS), published in 2021, to examine health behaviours among Korean adolescents. The KYRBS has been conducted annually since 2005 by the Korea Disease Control and Prevention Agency (KDCA) and the Ministry of Education. This is a foundational dataset for formulating adolescent health policies and promotion programmes. The 17th KYRBS dataset analysed in this study comprised data collected in 2020 during the early phase of the COVID-19 pandemic and released in 2021. The target population for this survey included all middle- and high-school students in Korea as of April 2020. Participants were selected using stratified cluster sampling, which involved three stages: stratification, sample allocation, and sampling. Stratification was based on 39 regional clusters and school types (middle, general, and vocational high schools), resulting in 117 strata. Sample allocation was conducted using proportional allocation methods by dividing the sample into 400 middle and 400 high schools. The sampling units were selected in two stages: schools as the primary sampling units and classes as the secondary sampling units. Owing to the challenges posed by the COVID-19 pandemic, such as increased workloads for survey-supporting teachers and restrictions on computer lab use, data collection was completed in 796 schools (399 middle schools and 397 high schools) instead of the planned 800 schools. A total of 54,848 students participated in the study, with a student-level response rate of 92.9%. Data were collected through anonymous, self-reported online surveys structured to prevent missing responses. Participants could not proceed to the next question without answering the current one. Consequently, there were no missing values in the dataset. All 54,848 responses were included in the analysis. The data collection period for the 17th KYRBS was from August to November 2020. Considering the unique circumstances of the COVID-19 pandemic, items on loneliness and anxiety disorders were added to the 2020 survey. The survey included 113 items covering socioeconomic status, academic performance, smoking, drinking, physical activity, and dietary habits. The KYRBS is a publicly available secondary dataset containing de-identified information. The Institutional Review Board of a university obtained ethical approval for the exemption on 8 February 2024 (No. [Anonymized]). 2.2. Research Instruments This study categorised the survey items into general and mental health characteristics. Each variable was reclassified and defined as follows: 2.2. 1 General Characteristics The general characteristics of the participants included sex, school level, economic status, economic changes during COVID-19, living with family, alcohol consumption, smoking, academic performance, stress levels, and fatigue recovery through sleep. Economic status was initially divided into five categories but was reclassified into three categories: high (high and upper-middle), middle, and low (low and lower-middle). Economic changes during COVID-19 were measured using the question, ‘Has your family’s economic status worsened owing to COVID-19?’ Responses were reclassified into ‘No’ (not at all, slightly not) and ‘Yes’ (somewhat, strongly agree). Academic performance was assessed using the following question: ‘How would you describe your academic performance over the past 12 months?’ The responses were reclassified into three categories: high (high and upper-middle), middle, and low (low and lower-middle). Living with family was determined by asking, ‘What is your current living arrangement?’ Participants living with family were categorised as ‘Yes’, while those living in dormitories, boarding houses, or other arrangements were classified as ‘No’. Subjective health status was measured using the following question: ‘How would you rate your overall health?’ Responses were categorised as ‘Good’ (very healthy, healthy), ‘Moderate’ (moderate), and ‘Poor’ (unhealthy, very unhealthy). Alcohol and smoking were assessed by asking about lifetime experiences with drinking and smoking, and responses were retained as ‘No’ and ‘Yes’. Stress levels were measured using the following question: ‘How often do you feel stressed?’ Responses were categorised as ‘Low’ (rarely, never), ‘Moderate’ (sometimes), and ‘High’ (frequently, very frequently). Fatigue recovery through sleep was measured by asking, ‘In the past 7 days, do you think your sleep was sufficient to recover from fatigue?’ Responses were categorised as ‘Enough’ (very sufficient, sufficient), ‘Moderate’ (neither), and ‘Insufficient’ (insufficient, very insufficient). 2.2.2 Mental Health-Related Characteristics Depression during COVID-19 was measured using the COVID-19 pandemic. ‘How has your level of depression changed?’ Responses were categorised into three groups: ‘Decrease’ (significantly decreased, decreased), ‘Similar’ (no change), and ‘Increase’ (increased, significantly increased). Anxiety was assessed using the Generalised Anxiety Disorder Scale (GAD-7), which includes seven items based on the question, ‘Over the past two weeks, how often have you been bothered by the following problems?’ Items include the following: ‘Feeling nervous, anxious, or on edge’, ‘Not being able to stop or control worrying’, ‘Worrying too much about different things’, ‘Having trouble relaxing’, ‘Being so restless that it is hard to sit still’, ‘Becoming easily annoyed or irritable’, and ‘Feeling afraid as if something awful might happen’. Responses were provided on a four-point Likert scale. Further, total scores were classified as ‘Almost none’ (≤ 9), ‘Moderate’ (10–14), and ‘High’ (≥ 15). Loneliness was measured using the following question: ‘Over the past 12 months, how often have you felt lonely?’ Responses were reclassified as ‘Almost none’ (never, rarely), ‘Moderate’ (sometimes), and ‘High’ (often, always). Suicidal ideation was measured using the question, ‘In the past 12 months, have you ever thought about suicide?’ Responses were categorised as ‘No’ and ‘Yes’, maintaining the original classification. This categorisation approach ensures consistency with the variables presented in Tables 1 and 2 , supporting an accurate analysis and interpretation. 2.3. Data Analysis Data analysis was conducted using the SPSS Windows software version 21.0. Following the guidelines provided in the KYRBS analysis manual, the study incorporated complex sample design elements, including stratification variables (strata), cluster variables (cluster), sampling weights (weight), and finite population correction factors (FPCF). This approach applies an unequal probability sampling design while controlling for the overestimation of variance. The online survey was designed to prevent unanswered items by requiring participants to respond to each question before proceeding to ensure that no missing data were present in the dataset. The Rao-Scott χ² test was employed to analyse frequency differences, and the study hypotheses were tested through a two-step analytical process. 2.4. Mediation Analysis Baron and Kenny’s ( 1986 ) three-step mediation analysis method was applied to examine whether anxiety mediates the relationship between Depression during COVID-19 and suicidal ideation. The analytical procedure was as follows: In Step 1, a complex-sample logistic regression analysis was conducted to determine the effect of the independent variable (Depression during COVID-19) on the dependent variable (suicidal ideation). In Step 2, a complex sample linear regression analysis was used to evaluate the effect of the independent variable (Depression during COVID-19) on the mediator (anxiety). As anxiety was treated as an ordinal variable, this method was deemed appropriate. In Step 3, the independent variable (Depression during COVID-19) and mediator (anxiety) were simultaneously entered into a complex sample logistic regression analysis to assess their effects on the dependent variable (suicidal ideation). This step specifically examined whether the impact of the independent variable on the dependent variable was reduced compared to Step 1. The statistical significance of the mediation effect was verified using the Sobel test. 2.5. Moderation Analysis The moderating effect of loneliness (V) on the relationship between anxiety (M) and suicidal ideation (Y) was examined using the following steps. First, the effect of anxiety (M) on the dependent variable—suicidal ideation (Y)—was analysed using complex sample logistic regression analysis. Similarly, the effect of loneliness (V) on suicidal ideation was assessed using logistic regression analysis. Second, a logistic regression analysis was performed to determine the effect of the interaction between anxiety (M) and loneliness (V) on suicidal ideation. This step aimed to evaluate whether loneliness moderated the relationship between anxiety and suicidal ideation. 3. Results 3.1. Differences in Suicidal Ideation According to the Characteristics of Adolescents Significant differences in suicidal ideation were observed according to adolescents’ general and health-related characteristics (Table 1 ). Female students (16.1%) reported significantly higher suicidal ideation than male students (9.5%) (p<.001). Middle school students (13.4%) exhibited higher suicidal ideation than high school students (12.0%) (p<.001). Economic status was closely associated with suicidal ideation, with students from low economic backgrounds (21.6%) showing significantly higher suicidal ideation than those from middle (11.9%) or high economic backgrounds (11.3%) (p<.001). Students who experienced economic change during the COVID-19 pandemic (16.5%) reported higher suicidal ideation than those who did not (11.1%) (p<.001). Students with low academic performance (15.4%) demonstrated significantly higher suicidal ideation than those with high academic performance (11.5%) (p<.001). Adolescents who did not live with their families (19.0%) showed higher suicidal ideation than those who lived with their families (12.5%) (p<.001). Students who reported poor health (29.3%) had significantly higher suicidal ideation rates than those who reported good health (8.9%) (p<.001). Alcohol and smoking experiences were also associated with suicidal ideation; students with alcohol (17.0%) and smoking experiences (21.6%) had significantly higher suicidal ideation than those without these experiences (p<.001). Stress levels showed a strong association with suicidal ideation, as students experiencing high levels of stress (25.4%) exhibited higher suicidal ideation than those experiencing little or no stress (2.0%) (p<.001). Finally, students who reported insufficient recovery from fatigue through sleep (17.7%) had higher suicidal ideation rates than those who reported sufficient recovery (7.2%) (p<.001). The results revealed significant differences in suicidal ideation among adolescents based on mental health-related characteristics, including levels of loneliness, anxiety, and changes in depression during the COVID-19 pandemic (Table 2 ). There was a notable variation in suicidal ideation according to loneliness level. Adolescents who reported high levels of loneliness exhibited a markedly higher prevalence of suicidal ideation (40.0%) than those who reported low levels of loneliness (3.8%), representing an approximately tenfold increase (p<.001). Similarly, differences in suicidal ideation were observed across anxiety levels. Adolescents with high anxiety levels showed a significantly higher prevalence of suicidal ideation (54.9%) than those with minimal anxiety (8.5%), indicating a nearly nine-fold increase in anxiety (p<.001). Furthermore, changes in depressive symptoms during the COVID-19 pandemic were significantly associated with suicidal ideation. Adolescents who experienced an increase in depression reported a higher prevalence of suicidal ideation (24.3%) than those whose depressive symptoms decreased (7.7%) or remained stable (5.6%) (p<.001). These findings underscore the substantial impact of mental health factors on suicidal ideation, particularly in the context of a global crisis such as the COVID-19 pandemic. [Insert Table 1 here] [Insert Table 2 here] 3.2. Mediation Analysis: Mediating Role of Anxiety in the Relationship Between Depression During COVID-19 and Suicidal Ideation This study employed Baron and Kenny’s ( 1986 ) three-step mediation analysis to examine whether anxiety mediated the relationship between depression during the COVID-19 pandemic and suicidal ideation (Table 3 ). First, a complex sample linear regression analysis was performed to investigate the impact of depression during COVID-19 on anxiety during a complex sample linear regression analysis was performed. The results revealed that depression during the COVID-19 pandemic had a significantly positive effect on anxiety (B = 0.18, SE = 0.004, t = 46.57, p < .001). This indicated that higher levels of depression were associated with higher levels of anxiety. The model fit was confirmed using Wald’s F(p) = 2168.86 (p < .001) and R² = 0.056. Next, the direct effect of depression during the COVID-19 pandemic on suicidal ideation was examined using complex sample logistic regression analysis. Depression during COVID-19 was found to have a significant direct impact on suicidal ideation (B = 1.28, SE = 0.031, t = 41.56, p < .001), with an odds ratio (OR) of 3.60 (95% CI: 3.388–3.823). This suggests that an increase in depression during the COVID-19 pandemic was associated with a higher likelihood of suicidal ideation. The model fit was Wald F(p) = 1727.00 (p < .001) and McFadden R² = 0.075. Finally, to test the mediating effects of anxiety, depression during COVID-19, and anxiety were simultaneously included in the model to predict suicidal ideation (Fig. 2 ). The results demonstrated that depression (B = 0.97, SE = 0.031, t = 31.09, p < .001) and anxiety (B = 1.20, SE = 0.023, t = 52.97, p < .001) significantly influenced suicidal ideation. Anxiety partially mediated the relationship between depression during the COVID-19 pandemic and suicidal ideation, as confirmed by the Sobel test (Z = 36.91, p < .001). The model fit was further supported by Wald’s F(p) = 2370.493 (p < .001) and McFadden’s R² = 0.147. The odds ratios (ORs) for depression and anxiety during the COVID-19 pandemic were 2.64 (95% CI: 2.486–2.811) and 3.31 (95% CI: 3.166–3.460), respectively. These findings indicate that a one-unit increase in depression during COVID-19 increases the likelihood of suicidal ideation by 2.64 times, while a one-unit increase in anxiety raises it by 3.31 times. These results highlight the critical mediating role of anxiety and emphasise the importance of addressing anxiety in interventions aimed at reducing suicidal ideation among adolescents. [Insert Table 3 here] [Insert Fig. 2 here] 3.3. Moderation Analysis: Moderating Role of Loneliness in the Relationship Between Anxiety and Suicidal Ideation A complex sample logistic regression analysis was conducted to examine the moderating role of loneliness in the relationship between anxiety and suicidal ideation among adolescents (Table 4 ). First, the impact of anxiety on suicidal ideation was analysed. The results revealed that anxiety (M) had a significant positive effect on suicidal ideation (Y) (B = 1.42, SE = 0.022, t = 65.44, p < .001). Specifically, a one-unit increase in anxiety was associated with a 4.13-fold higher likelihood of suicidal ideation (95% CI: 3.958–4.310). The model fit was confirmed using Wald’s F(p) = 5501.75 (p < .001) and McFadden’s R² = 0.159. Next, we examined the effect of loneliness on suicidal ideation. The findings indicated that loneliness (V) also had a significant positive impact on suicidal ideation (B = 1.44, SE = 0.021, t = 69.68, p < .001). A one-unit increase in loneliness corresponded to a 4.22-fold higher likelihood of suicidal ideation (95% CI, 4.051–4.219). The model fit for this analysis was Wald F(p) = 4855.40 (p < .001) and McFadden R² = 0.158. Finally, the interaction effect between anxiety and loneliness (M*V) on suicidal ideation was tested to determine whether loneliness moderated the relationship between anxiety and suicidal ideation (Fig. 3 ). The results confirmed that the interaction term had a significantly positive effect on suicidal ideation (B = 0.52, SE = 0.008, t = 68.50, p < .001). The odds ratio for the interaction effect was 1.68 (95% CI: 1.654–1.679)—a one-unit increase in the interaction between anxiety and loneliness increases the likelihood of suicidal ideation by 1.68 times. This finding highlights that loneliness serves as a critical moderating variable amplifying the relationship between anxiety and suicidal ideation. The model fit was Wald F(p) = 4692.616 (p < .001) and McFadden R² = 0.164. Overall, the model fit indices show a progressive increase in McFadden R² values across the three steps, from 0.159 in the first step to 0.164 in the final step. This incremental improvement underscores the importance of loneliness in the relationship between anxiety and suicide ideation. These results suggest that adolescents experiencing high levels of anxiety and loneliness are at a significantly greater risk of developing suicidal ideation, emphasising the need for targeted interventions addressing loneliness to mitigate this risk. [Insert Table 4 here] [Insert Fig. 3 here] 4. Discussion This study explored the complex pathways through which depression, anxiety, and loneliness influence suicidal ideation among adolescents during the COVID-19 pandemic. The findings demonstrated that COVID-19-related depression indirectly influenced suicidal ideation through anxiety and that loneliness moderated the relationship between anxiety and suicidal ideation. These results provide critical insights into adolescent mental health during social crises such as the pandemic and highlight the essential considerations for developing effective intervention strategies. 4.1. Mediating Relationship of Coronavirus Disease 2019-Related Depression, Anxiety, and Suicidal Ideation First, the results confirmed that COVID-19-related depression significantly impacted suicidal ideation directly and indirectly through anxiety. This finding suggests that depression increases the risk of suicidal ideation and amplifies anxiety, further exacerbating suicidal thoughts. Prior studies support these findings—reducing depression can lower suicidal ideation by 24%, whereas addressing anxiety can lead to a 74% reduction in suicidal ideation (Metts et al. 2023 ). Adolescence is a developmental period characterised by a heightened vulnerability to anxiety, and reports have indicated a marked increase in anxiety disorders among adolescents during the pandemic (Foster et al. 2023 ; Kiviruusu et al. 2023 ). Risk factors for adolescent anxiety during the pandemic included sex (women), remote learning, younger age, financial difficulties, and future (Jung et al. 2022 ; Muzaffar et al. 2022 ; Foster et al. 2023 ; Kiviruusu et al. 2023 ). This study highlights the pivotal role of anxiety as a mechanism by which depression influences suicidal ideation, emphasising the need for integrated mental health strategies that address the interplay between these factors. 4.2. Moderating Role of Loneliness Second, the study found that loneliness moderates the relationship between anxiety and suicidal ideation. While the existing research has primarily focused on the direct link between loneliness and suicidal ideation (Schinka et al. 2012 ; Wang et al. 2025 ), this study identified a specific moderating role of loneliness in amplifying the impact of anxiety on suicidal ideation. Loneliness is an emotional state and a risk factor associated with negative thought patterns, substance abuse, sleep disturbances, and even increased mortality (Holt-Lunstad et al. 2010 ; Masi et al. 2011 ; Doane & Thurston 2014 ; Rönkä et al. 2014 ). Adolescents experience heightened loneliness during the pandemic due to prolonged social isolation (Thakur et al. 2023 ). Research has suggested that the duration of loneliness, rather than its intensity, significantly affects mental health outcomes (Loades et al. 2020 ). This underscores the importance of targeting loneliness in interventions aimed at enhancing adolescent mental health during periods of social isolation. Although family functioning and peer connections do not mitigate depression directly, they may alleviate loneliness, highlighting the importance of loneliness-focused interventions (Vacaru et al. 2022 ). 4.3. Interaction Among Depression, Anxiety, and Loneliness Third, loneliness significantly moderates the pathway through which COVID-19-related depression indirectly influences suicidal ideation through anxiety. Higher levels of loneliness had more potent indirect effects. This aligns with Liang’s (2023) findings that demonstrate the interdependent development of depression, social anxiety, and loneliness. This study further elaborates on these relationships by revealing their complex interactions in predicting suicidal ideation. The interpersonal-psychological theory of suicide identifies a lack of belongingness as a critical predictor of suicidal ideation (Ma et al. 2016 ). During the pandemic, an abrupt increase in social disconnection heightened loneliness, which amplified the risk of suicidal ideation. This finding emphasises the need to prioritise interventions addressing loneliness to prevent suicidal ideation during crises. 4.4. Implications and Limitations This study provides important insights for the prevention of suicidal ideation in adolescents. Protective factors against loneliness, such as social support (McMahon et al. 2023 ), family connections (Al Omari et al. 2023 ), a sense of belonging (Joiner 2009 ), and peer support (Pandey et al. 2019 ; Aboagye et al. 2022 ), can significantly mitigate mental health challenges. However, research has shown that virtual interactions during the pandemic have not fully satisfied relational needs (McMahon et al. 2023 ), and Gallagher (2014) noted that social support alone may be insufficient for suicide prevention. Therefore, it is critical to address the emotional aspects of loneliness. Mental health professionals should actively assess and intervene in adolescent loneliness during crises. Thus, innovative strategies for fostering belongingness, even in remote environments, are urgently required. This study had several limitations. First, it used cross-sectional data collected in 2020, limiting its ability to determine long-term causal relationships among the variables. Future longitudinal studies are necessary to examine these changes over time. Second, subjective bias may have influenced self-reported survey data, necessitating the inclusion of objective and multidimensional data collection methods. Third, the study focused on Korean adolescents, and further research is required to generalise the findings to other cultural contexts. Nevertheless, this study makes a significant contribution by empirically elucidating the complex interplay between depression, anxiety, loneliness, and suicidal ideation in the unique context of the COVID-19 pandemic. By integrating these psychological factors, our findings offer practical and evidence-based guidance for developing targeted intervention strategies to enhance adolescent mental health and prevent suicidal ideation during future social crises. Declarations Ethical approval statement: All participants provided informed consent or assent. The Institutional Review Board of a university approved the study on 8 February 2024 (no. [Anonymized]). Human Ethics and Consent to Participate declarations: Not applicable Patient Consent Statement: This study was not obtained patient/parent/guardian consent because it is secondary data analysis research. Funding Information: This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (Grant no. RS-2023-NR076968). Author Contribution Statement : EC and YC wrote the main manuscript text and EC prepared figures and tables. All authors reviewed the manuscript. 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Longitudinal associations among dimensional symptoms of depression and anxiety and first onset suicidal ideation in adolescents. Suicide Life‐Threatening Behav. 3 (3), 457–469. https://doi.org/10.1111/sltb.12956 (2023). Ministry of Health and Welfare. Mental health report. South Korea: Ministry of Health and Welfare. (2022). Available from: https://seoulmentalhealth.kr/library/paper-collections/347 Motillon-Toudic, C. et al. Social isolation and suicide risk: literature review and perspectives. Eur. psychiatry . 65 (1), e65. https://doi.org/10.1192/j.eurpsy.2022.2320 (2022). Muzaffar, R. et al. Generalized anxiety disorder among Bangladeshi university students during COVID-19 pandemic: gender specific findings from a cross-sectional study. Discover mental health . 2 (1), 3. https://doi.org/10.1007/s44192-022-00005-2 (2022). Racine, N. et al. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. 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Child and adolescent mental health , 27(2), 173–189. (2022). https://doi.org/10.1111/camh.12501 Schinka, K. C., VanDulmen, M. H., Bossarte, R. & Swahn, M. Association between loneliness and suicidality during middle childhood and adolescence: longitudinal effects and the role of demographic characteristics. J. Psychol. 146 (1–2), 105–118. https://doi.org/10.1080/00223980.2011.584084 (2012). Schnitzer, P. G., Dykstra, H. & Collier, A. The COVID-19 pandemic and youth suicide: 2020–2021. Pediatrics 151 (3), e2022058716. https://doi.org/10.1542/peds.2022-058716 (2023). Steinberg, L. & Morris, A. S. Adolescent development. Ann. Rev. Psychol. 52 , 83–110. https://doi.org/10.1146/annurev.psych.52.1.83 (2001). Thakur, H., Stutts, M., Choi, J. W., Temple, J. R. & Cohen, J. R. Adolescent loneliness during the COVID-19 pandemic: the role of pre-pandemic risk factors. Child Indic. Res. 16 (2), 617–639. https://doi.org/10.1007/s12187-022-09984-8 (2023). Theberath, M. et al. Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies. SAGE open. medicine , 10 , 20503121221086712. https://doi.org/10.1177/20503121221086712 Vacaru, S. V., Beijers, R. & de Weerth, C. Internalizing symptoms and family functioning predict adolescent depressive symptoms during COVID-19: A longitudinal study in a community sample. PloS one . 17 (3), e0264962. https://doi.org/10.1371/journal.pone.0264962 (2022). Wang, D. et al. Longitudinal trajectories of depression and anxiety among adolescents during COVID-19 lockdown in China. J. Affect. Disord. 299 , 628–635. https://doi.org/10.1016/j.jad.2021.12.086 (2022). Wang, J. et al. Loneliness, internalizing and externalizing problems, and suicidal ideation among Chinese adolescents: a longitudinal mediation analysis. J. Adolesc. Health . 76 (1), 96–104. https://doi.org/10.1016/j.jadohealth.2024.08.010 (2025). Wiederhold, B. K. The escalating crisis in adolescent mental health. Cyberpsychology Behav. Social Netw. 25 (2), 81–82. https://doi.org/10.1089/cyber.2022.29237.editorial (2022). Tables Table 1. Differences in Suicidal Ideation According to General and Health-Related Characteristics of Adolescents N=54,848 Variables Categories Suicidal ideation Suicidal ideation Rao-Scott p No (n=47,892) Yes (n= 6956) n (%) n (%) Sex Men 25,762 (90.5) 2,639 (9.5) 395.57 <.001 Women 22,130 (83.9) 4,317 (16.1) School Middle 26,047 (86.6) 3,968 (13.4) 12.82 <.001 High 21,845 (88.0) 2,988 (12.0) Economic status High 19,139 (88.7) 2,429 (11.3) 218.45 <.001 Middle 23,892 (88.1) 3,185 (11.9) Low 4,861 (78.4) 1,342 (21.6) Economic changes during COVID-19 No 33,912 (88.9) 4,224 (11.1) 284.69 <.001 Yes 13,980 (83.5) 2,732 (16.5) Academic performance High 18,202 (88.5) 2,326 (11.5) 75.77 <.001 Middle 14,977 (88.5) 1,926 (11.5) Low 14,713 (84.6) 2,704 (15.4) Living with family No 45,902 (87.5) 6,524 (12.5) 47.18 <.001 Yes 1,990 (81.0) 432 (19.0) Health status Good 32,437 (91.1) 3,092 (8.9) 948.02 <.001 Moderate 11,930 (83.6) 2,368 (16.4) Poor 3,525 (70.7) 1,496 (29.3) Alcohol No 33,015 (89.4) 3,894 (10.6) 371.47 <.001 Yes 14,877 (83.0) 3,062 (17.0) Smoking No 43,719 (88.3) 5,800 (11.7) 351.59 <.001 Yes 4,173 (78.4) 1,156 (21.6) Stress Not 10,169 (98.0) 208 (2.0) 2343.34 <.001 Moderate 21,881 (94.1) 1,345 (5.9) High 15,842 (74.6) 5,403 (25.4) Fatigue recovery Enough 11,934 (92.8) 905 (7.2) 501.60 <.001 Moderate 16,176 (90.3) 1,735 (9.7) Insufficiency 19,782 (82.3) 4,316 (17.7) Note: COVID-19, Coronavirus disease 2019 Table 2. Differences in Suicidal Ideation According to Mental Health Characteristics of Adolescents N=54,848 Variables Categories Suicidal ideation Suicidal ideation Rao-Scott p No (n=47,892) Yes (n= 6956) n (%) n (%) Loneliness Almost none 25,346 (96.2) 975 (3.8) 3225.55 <.001 Moderate 17,306 (87.6) 2,466 (12.4) High 5,240 (60.0) 3,515 (40.0) Anxiety Almost none 44,075 (91.5) 4,068 (8.5) 3276.34 <.001 Moderate 2,832 (63.8) 1,639 (36.2) High 985 (45.1) 1,249 (54.9) Depression during COVID-19 Decrease 5,151 (92.3) 392 (7.7) 1717.73 <.001 Similar 27,871 (94.4) 1,691 (5.6) Increase 14,858 (75.7) 4,872 (24.3) Note: COVID-19, Coronavirus disease 2019 Table 3. Mediating Effects of Anxiety on Depression During Coronavirus Disease 2019 and Suicidal Ideation N=54,848 Step Variable → Dependent B SE t(p) OR 95% CI LLCI ULCI 1 Depression during COVID-19 (X) Anxiety (M) 0.18 0.004 46.57 (<.001) N/A .168 .183 Model fit Model fit: Wald F(p) 2168.86 (<.001), R 2 (.056) 2 Depression during COVID-19 (X) Suicidal ideation (Y) 1.28 0.031 41.56 (<.001) 3.60 3.388 3.823 Model fit Model fit: Wald F(p) 1727.00 (<.001), McFadden R 2 (.075) 3 Depression during COVID-19 (X) Suicidal ideation (Y) 0.97 0.031 31.09 (<.001) 2.64 2.486 2.811 Anxiety (M) 1.20 0.023 52.97 (<.001) 3.31 3.166 3.460 Model fit Model fit: Wald F(p) 2370.493 (<.001), McFadden R 2 (.147) Sobel test Z=36.91 (<.001) Note: COVID-19, Coronavirus disease 2019; B, coefficient; LLCI, lower limit confidence interval; M, mediate variable; OR, odds ratio; SE, standard error; ULCI, upper limit confidence interval; X, independent variable; Y, independent variable. Table 4. Moderating Effects of Loneliness on Anxiety and Suicidal Ideation N=54,848 Step Variable → Dependent B SE t(p) OR 95% CI LLCI ULCI 1 Anxiety (M) Suicidal ideation (Y) 1.42 0.022 65.44 (<.001) 4.13 3.958 4.310 Model fit Wald F(p) 5501.75(<.001), McFadden R 2 (.159) 2 Loneliness (V) Suicidal ideation (Y) 1.44 0.021 69.68 (<.001) 4.22 4.219 4.051 Model fit Wald F(p) 4855.40 (<.001), McFadden R 2 (.158) 3 Anxiety* Loneliness (M*V) Suicidal ideation (Y) 0.52 0.008 68.50 (<.001) 1.68 1.679 1.654 Model fit Wald F(p) 4692.616 (<.001), McFadden R 2 (.164) Note: B, coefficient; LLCI, lower limit confidence interval; OR, odds ratio; SE, standard error; ULCI, upper-limit confidence interval; V, moderated variable; X, independent variable; Y, independent variable. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9343756","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":637826642,"identity":"3931a6fb-d5df-4ceb-a8c0-b373e28c4461","order_by":0,"name":"Eun-Joo Choi","email":"","orcid":"","institution":"Kyung-In Women's University","correspondingAuthor":false,"prefix":"","firstName":"Eun-Joo","middleName":"","lastName":"Choi","suffix":""},{"id":637826643,"identity":"2fdf637f-f599-4a96-a0d7-983b037b8a99","order_by":1,"name":"Yun-Jung 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10:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9343756/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9343756/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109324963,"identity":"162f6303-21ae-4617-a2ec-a8604cb1eb20","added_by":"auto","created_at":"2026-05-15 14:32:05","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":133711,"visible":true,"origin":"","legend":"\u003cp\u003eThe research model.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9343756/v1/978d39125e7efa38d4b45b60.jpeg"},{"id":109324965,"identity":"217c1bf1-ad04-4648-b643-ddfab042c48e","added_by":"auto","created_at":"2026-05-15 14:32:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19264,"visible":true,"origin":"","legend":"\u003cp\u003eStatistical model of mediation\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eNote:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003ea path:\u003c/strong\u003e Effect of X on M, \u003cstrong\u003eb₁ path:\u003c/strong\u003e Effect of M on Y, \u003cstrong\u003ec path:\u003c/strong\u003e Direct effect of X on Y, \u003cstrong\u003ec' path:\u003c/strong\u003e Total effect of X on Y controlling for M, \u003cstrong\u003eM:\u003c/strong\u003e Mediator variable, \u003cstrong\u003eX:\u003c/strong\u003e Independent variable, \u003cstrong\u003eY:\u003c/strong\u003e Dependent variable.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9343756/v1/bef022c71d00ab85b9c4026d.png"},{"id":109405507,"identity":"e673e9ab-81ca-4cb2-a130-9501377b519e","added_by":"auto","created_at":"2026-05-17 13:18:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21386,"visible":true,"origin":"","legend":"\u003cp\u003eStatistical model of moderated mediation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eNote:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e a path:\u003c/strong\u003e Effect of X on M, \u003cstrong\u003eb₁ path:\u003c/strong\u003e Effect of M on Y, \u003cstrong\u003eb₂ path:\u003c/strong\u003e Effect of V on Y, \u003cstrong\u003eb₃ path:\u003c/strong\u003e Interaction effect of M*V on Y, \u003cstrong\u003ec path:\u003c/strong\u003e Direct effect of X on Y, \u003cstrong\u003eM:\u003c/strong\u003e Mediator variable, \u003cstrong\u003eM*V:\u003c/strong\u003eInteraction term between M and V, \u003cstrong\u003eV:\u003c/strong\u003e Moderator variable, \u003cstrong\u003eX:\u003c/strong\u003eIndependent variable, \u003cstrong\u003eY:\u003c/strong\u003e Dependent variable.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9343756/v1/a30eacdfbd3c7560d74edfcf.png"},{"id":109406105,"identity":"7e4508a8-498a-4ee2-8d48-54e9226d1b09","added_by":"auto","created_at":"2026-05-17 13:24:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":572044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9343756/v1/c1563f8b-17af-419a-b52c-0bf44ded9ac2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Impact of Depression during COVID-19 on Suicidal Ideation in Adolescents: Anxiety as a Mediator and Loneliness as a Moderator\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAdolescent suicide rates are a critical global social issue that has increased significantly following the coronavirus disease 2019 (COVID-19) pandemic. Notably, during the early stages of the pandemic in 2020, while general suicide rates in countries such as the United States, Japan, and South Korea declined compared to those in 2019, adolescent suicide rates increased by 9%. This trend highlights adolescent suicide as an urgent public health and societal challenge requiring immediate attention (Ministry of Health and Welfare \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bridge et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Fushimi \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdolescence is characterised by rapid biological and emotional changes that make individuals particularly vulnerable to mental health issues. Psychological traits, such as experiential avoidance, during this stage are associated with an increased risk of developing psychosocial disorders (Theberath et al. 2022). Conditions such as anxiety, depression, and phobias are highly prevalent among adolescents, further underscoring their susceptibility to mental health vulnerabilities (Costello et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). When left unaddressed, these mental health problems can have negative long-term consequences on adolescents\u0026rsquo; quality of life and functioning, extending into adulthood.\u003c/p\u003e \u003cp\u003eThe coronavirus disease (COVID-19) pandemic has exacerbated mental health crises among adolescents (Wiederhold \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Public health measures implemented to mitigate viral transmission, such as school closures, restrictions on outdoor activities, and social isolation, have disrupted daily routines and contributed to psychological distress (Samji et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies indicate that the prevalence of anxiety and depression among adolescents has risen significantly during the pandemic compared to pre-pandemic levels (Racine et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Samji et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Theberath et al. 2022). Depression and anxiety are the major predictors of mental disorders and suicidal ideation among adolescents (Schnitzer et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Wang et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found that the prevalence of depression and anxiety peaked during the later stages of pandemic-related restrictions, and longer lockdowns further exacerbated these issues.\u003c/p\u003e \u003cp\u003eAdolescent suicide is widely known to be influenced by various mental health and life stress factors. However, during the pandemic, social isolation due to school closures and home confinement have emerged as key factors contributing to adolescent suicide. The pandemic has disrupted social support systems and mental health services, amplifying suicide risk (Schnitzer et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). While the pandemic has highlighted the interplay among depression, anxiety, and social isolation, comprehensive studies examining their combined impact on suicidal ideation remain limited.\u003c/p\u003e \u003cp\u003eResearch conducted during the lockdown period has revealed that adolescents experience severe loneliness due to restricted social interactions, identifying loneliness as a significant stressor (Cooper et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Al Omari et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Social isolation affects younger individuals more adversely (Alam et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Although adolescent use of social media and online interactions increased during the pandemic, these virtual connections were not perceived as adequate substitutes for in-person interactions (Asscheman et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Existing studies demonstrate strong correlations between loneliness, depression, and anxiety, with these variables mutually influencing each other (Gadassi Polack et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Barbieri \u0026amp; Mercado \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Al Omari et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Cena et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Adolescents reporting higher levels of loneliness were four times more likely to experience suicidal ideation, emphasising the importance of addressing loneliness as a strategy for suicide prevention (Macalli et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile this study confirmed the significant roles of depression, anxiety, and loneliness in influencing suicidal ideation among adolescents during the pandemic, it sought to fill this gap by understanding the interactive mechanisms among these factors. Therefore, this study proposes the following hypotheses (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCOVID-19-related depression affects suicidal ideation directly and indirectly through anxiety as a mediator.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLoneliness moderates the relationship between anxiety and suicidal ideation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe indirect effect of COVID-19-related depression on suicidal ideation, mediated by anxiety, differs by levels of loneliness.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003eThis study aimed to elucidate the complex interplay between depression, anxiety, and loneliness in influencing suicidal ideation during the COVID-19 pandemic. The study sought to uncover the interactive mechanisms of adolescent mental health by integrating the mediating role of anxiety and the moderating role of loneliness. The findings of this study are expected to provide practical insights into suicide prevention and mental health promotion during social crises and offer actionable guidelines for public health and mental health management practices.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1. Research Design\u003c/h2\u003e\n \u003cp\u003eThis study used data from the 17th Korea Youth Risk Behavior Web-based Survey (KYRBS), published in 2021, to examine health behaviours among Korean adolescents. The KYRBS has been conducted annually since 2005 by the Korea Disease Control and Prevention Agency (KDCA) and the Ministry of Education. This is a foundational dataset for formulating adolescent health policies and promotion programmes. The 17th KYRBS dataset analysed in this study comprised data collected in 2020 during the early phase of the COVID-19 pandemic and released in 2021.\u003c/p\u003e\n \u003cp\u003eThe target population for this survey included all middle- and high-school students in Korea as of April 2020. Participants were selected using stratified cluster sampling, which involved three stages: stratification, sample allocation, and sampling. Stratification was based on 39 regional clusters and school types (middle, general, and vocational high schools), resulting in 117 strata. Sample allocation was conducted using proportional allocation methods by dividing the sample into 400 middle and 400 high schools. The sampling units were selected in two stages: schools as the primary sampling units and classes as the secondary sampling units.\u003c/p\u003e\n \u003cp\u003eOwing to the challenges posed by the COVID-19 pandemic, such as increased workloads for survey-supporting teachers and restrictions on computer lab use, data collection was completed in 796 schools (399 middle schools and 397 high schools) instead of the planned 800 schools. A total of 54,848 students participated in the study, with a student-level response rate of 92.9%. Data were collected through anonymous, self-reported online surveys structured to prevent missing responses. Participants could not proceed to the next question without answering the current one. Consequently, there were no missing values in the dataset. All 54,848 responses were included in the analysis.\u003c/p\u003e\n \u003cp\u003eThe data collection period for the 17th KYRBS was from August to November 2020. Considering the unique circumstances of the COVID-19 pandemic, items on loneliness and anxiety disorders were added to the 2020 survey. The survey included 113 items covering socioeconomic status, academic performance, smoking, drinking, physical activity, and dietary habits.\u003c/p\u003e\n \u003cp\u003eThe KYRBS is a publicly available secondary dataset containing de-identified information. The Institutional Review Board of a university obtained ethical approval for the exemption on 8 February 2024 (No. [Anonymized]).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2. Research Instruments\u003c/h2\u003e\n \u003cp\u003eThis study categorised the survey items into general and mental health characteristics. Each variable was reclassified and defined as follows:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2. 1 General Characteristics\u003c/h2\u003e\n \u003cp\u003eThe general characteristics of the participants included sex, school level, economic status, economic changes during COVID-19, living with family, alcohol consumption, smoking, academic performance, stress levels, and fatigue recovery through sleep. Economic status was initially divided into five categories but was reclassified into three categories: high (high and upper-middle), middle, and low (low and lower-middle). Economic changes during COVID-19 were measured using the question, \u0026lsquo;Has your family\u0026rsquo;s economic status worsened owing to COVID-19?\u0026rsquo; Responses were reclassified into \u0026lsquo;No\u0026rsquo; (not at all, slightly not) and \u0026lsquo;Yes\u0026rsquo; (somewhat, strongly agree).\u003c/p\u003e\n \u003cp\u003eAcademic performance was assessed using the following question: \u0026lsquo;How would you describe your academic performance over the past 12 months?\u0026rsquo; The responses were reclassified into three categories: high (high and upper-middle), middle, and low (low and lower-middle). Living with family was determined by asking, \u0026lsquo;What is your current living arrangement?\u0026rsquo; Participants living with family were categorised as \u0026lsquo;Yes\u0026rsquo;, while those living in dormitories, boarding houses, or other arrangements were classified as \u0026lsquo;No\u0026rsquo;. Subjective health status was measured using the following question: \u0026lsquo;How would you rate your overall health?\u0026rsquo; Responses were categorised as \u0026lsquo;Good\u0026rsquo; (very healthy, healthy), \u0026lsquo;Moderate\u0026rsquo; (moderate), and \u0026lsquo;Poor\u0026rsquo; (unhealthy, very unhealthy).\u003c/p\u003e\n \u003cp\u003eAlcohol and smoking were assessed by asking about lifetime experiences with drinking and smoking, and responses were retained as \u0026lsquo;No\u0026rsquo; and \u0026lsquo;Yes\u0026rsquo;. Stress levels were measured using the following question: \u0026lsquo;How often do you feel stressed?\u0026rsquo; Responses were categorised as \u0026lsquo;Low\u0026rsquo; (rarely, never), \u0026lsquo;Moderate\u0026rsquo; (sometimes), and \u0026lsquo;High\u0026rsquo; (frequently, very frequently). Fatigue recovery through sleep was measured by asking, \u0026lsquo;In the past 7 days, do you think your sleep was sufficient to recover from fatigue?\u0026rsquo; Responses were categorised as \u0026lsquo;Enough\u0026rsquo; (very sufficient, sufficient), \u0026lsquo;Moderate\u0026rsquo; (neither), and \u0026lsquo;Insufficient\u0026rsquo; (insufficient, very insufficient).\u003c/p\u003e\n \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n \u003ch2\u003e2.2.2 Mental Health-Related Characteristics\u003c/h2\u003e\n \u003cp\u003eDepression during COVID-19 was measured using the COVID-19 pandemic. \u0026lsquo;How has your level of depression changed?\u0026rsquo; Responses were categorised into three groups: \u0026lsquo;Decrease\u0026rsquo; (significantly decreased, decreased), \u0026lsquo;Similar\u0026rsquo; (no change), and \u0026lsquo;Increase\u0026rsquo; (increased, significantly increased). Anxiety was assessed using the Generalised Anxiety Disorder Scale (GAD-7), which includes seven items based on the question, \u0026lsquo;Over the past two weeks, how often have you been bothered by the following problems?\u0026rsquo; Items include the following: \u0026lsquo;Feeling nervous, anxious, or on edge\u0026rsquo;, \u0026lsquo;Not being able to stop or control worrying\u0026rsquo;, \u0026lsquo;Worrying too much about different things\u0026rsquo;, \u0026lsquo;Having trouble relaxing\u0026rsquo;, \u0026lsquo;Being so restless that it is hard to sit still\u0026rsquo;, \u0026lsquo;Becoming easily annoyed or irritable\u0026rsquo;, and \u0026lsquo;Feeling afraid as if something awful might happen\u0026rsquo;. Responses were provided on a four-point Likert scale. Further, total scores were classified as \u0026lsquo;Almost none\u0026rsquo; (\u0026le;\u0026thinsp;9), \u0026lsquo;Moderate\u0026rsquo; (10\u0026ndash;14), and \u0026lsquo;High\u0026rsquo; (\u0026ge;\u0026thinsp;15). Loneliness was measured using the following question: \u0026lsquo;Over the past 12 months, how often have you felt lonely?\u0026rsquo; Responses were reclassified as \u0026lsquo;Almost none\u0026rsquo; (never, rarely), \u0026lsquo;Moderate\u0026rsquo; (sometimes), and \u0026lsquo;High\u0026rsquo; (often, always). Suicidal ideation was measured using the question, \u0026lsquo;In the past 12 months, have you ever thought about suicide?\u0026rsquo; Responses were categorised as \u0026lsquo;No\u0026rsquo; and \u0026lsquo;Yes\u0026rsquo;, maintaining the original classification. This categorisation approach ensures consistency with the variables presented in Tables \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, supporting an accurate analysis and interpretation.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3. Data Analysis\u003c/h2\u003e\n \u003cp\u003eData analysis was conducted using the SPSS Windows software version 21.0. Following the guidelines provided in the KYRBS analysis manual, the study incorporated complex sample design elements, including stratification variables (strata), cluster variables (cluster), sampling weights (weight), and finite population correction factors (FPCF). This approach applies an unequal probability sampling design while controlling for the overestimation of variance.\u003c/p\u003e\n \u003cp\u003eThe online survey was designed to prevent unanswered items by requiring participants to respond to each question before proceeding to ensure that no missing data were present in the dataset. The Rao-Scott \u0026chi;\u0026sup2; test was employed to analyse frequency differences, and the study hypotheses were tested through a two-step analytical process.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4. Mediation Analysis\u003c/h2\u003e\n \u003cp\u003eBaron and Kenny\u0026rsquo;s (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1986\u003c/span\u003e) three-step mediation analysis method was applied to examine whether anxiety mediates the relationship between Depression during COVID-19 and suicidal ideation. The analytical procedure was as follows:\u003c/p\u003e\n \u003cp\u003eIn Step 1, a complex-sample logistic regression analysis was conducted to determine the effect of the independent variable (Depression during COVID-19) on the dependent variable (suicidal ideation). In Step 2, a complex sample linear regression analysis was used to evaluate the effect of the independent variable (Depression during COVID-19) on the mediator (anxiety). As anxiety was treated as an ordinal variable, this method was deemed appropriate. In Step 3, the independent variable (Depression during COVID-19) and mediator (anxiety) were simultaneously entered into a complex sample logistic regression analysis to assess their effects on the dependent variable (suicidal ideation). This step specifically examined whether the impact of the independent variable on the dependent variable was reduced compared to Step 1. The statistical significance of the mediation effect was verified using the Sobel test.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5. Moderation Analysis\u003c/h2\u003e\n \u003cp\u003eThe moderating effect of loneliness (V) on the relationship between anxiety (M) and suicidal ideation (Y) was examined using the following steps. First, the effect of anxiety (M) on the dependent variable\u0026mdash;suicidal ideation (Y)\u0026mdash;was analysed using complex sample logistic regression analysis. Similarly, the effect of loneliness (V) on suicidal ideation was assessed using logistic regression analysis. Second, a logistic regression analysis was performed to determine the effect of the interaction between anxiety (M) and loneliness (V) on suicidal ideation. This step aimed to evaluate whether loneliness moderated the relationship between anxiety and suicidal ideation.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Differences in Suicidal Ideation According to the Characteristics of Adolescents\u003c/h2\u003e\n \u003cp\u003eSignificant differences in suicidal ideation were observed according to adolescents\u0026rsquo; general and health-related characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Female students (16.1%) reported significantly higher suicidal ideation than male students (9.5%) (p\u0026lt;.001). Middle school students (13.4%) exhibited higher suicidal ideation than high school students (12.0%) (p\u0026lt;.001). Economic status was closely associated with suicidal ideation, with students from low economic backgrounds (21.6%) showing significantly higher suicidal ideation than those from middle (11.9%) or high economic backgrounds (11.3%) (p\u0026lt;.001). Students who experienced economic change during the COVID-19 pandemic (16.5%) reported higher suicidal ideation than those who did not (11.1%) (p\u0026lt;.001).\u003c/p\u003e\n \u003cp\u003eStudents with low academic performance (15.4%) demonstrated significantly higher suicidal ideation than those with high academic performance (11.5%) (p\u0026lt;.001). Adolescents who did not live with their families (19.0%) showed higher suicidal ideation than those who lived with their families (12.5%) (p\u0026lt;.001). Students who reported poor health (29.3%) had significantly higher suicidal ideation rates than those who reported good health (8.9%) (p\u0026lt;.001). Alcohol and smoking experiences were also associated with suicidal ideation; students with alcohol (17.0%) and smoking experiences (21.6%) had significantly higher suicidal ideation than those without these experiences (p\u0026lt;.001). Stress levels showed a strong association with suicidal ideation, as students experiencing high levels of stress (25.4%) exhibited higher suicidal ideation than those experiencing little or no stress (2.0%) (p\u0026lt;.001). Finally, students who reported insufficient recovery from fatigue through sleep (17.7%) had higher suicidal ideation rates than those who reported sufficient recovery (7.2%) (p\u0026lt;.001).\u003c/p\u003e\n \u003cp\u003eThe results revealed significant differences in suicidal ideation among adolescents based on mental health-related characteristics, including levels of loneliness, anxiety, and changes in depression during the COVID-19 pandemic (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a notable variation in suicidal ideation according to loneliness level. Adolescents who reported high levels of loneliness exhibited a markedly higher prevalence of suicidal ideation (40.0%) than those who reported low levels of loneliness (3.8%), representing an approximately tenfold increase (p\u0026lt;.001). Similarly, differences in suicidal ideation were observed across anxiety levels. Adolescents with high anxiety levels showed a significantly higher prevalence of suicidal ideation (54.9%) than those with minimal anxiety (8.5%), indicating a nearly nine-fold increase in anxiety (p\u0026lt;.001).\u003c/p\u003e\n \u003cp\u003eFurthermore, changes in depressive symptoms during the COVID-19 pandemic were significantly associated with suicidal ideation. Adolescents who experienced an increase in depression reported a higher prevalence of suicidal ideation (24.3%) than those whose depressive symptoms decreased (7.7%) or remained stable (5.6%) (p\u0026lt;.001). These findings underscore the substantial impact of mental health factors on suicidal ideation, particularly in the context of a global crisis such as the COVID-19 pandemic.\u003c/p\u003e\n \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\n \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3.2. Mediation Analysis: Mediating Role of Anxiety in the Relationship Between Depression During COVID-19 and Suicidal Ideation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThis study employed Baron and Kenny\u0026rsquo;s (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1986\u003c/span\u003e) three-step mediation analysis to examine whether anxiety mediated the relationship between depression during the COVID-19 pandemic and suicidal ideation (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). First, a complex sample linear regression analysis was performed to investigate the impact of depression during COVID-19 on anxiety during a complex sample linear regression analysis was performed. The results revealed that depression during the COVID-19 pandemic had a significantly positive effect on anxiety (B\u0026thinsp;=\u0026thinsp;0.18, SE\u0026thinsp;=\u0026thinsp;0.004, t\u0026thinsp;=\u0026thinsp;46.57, p \u0026lt; .001). This indicated that higher levels of depression were associated with higher levels of anxiety. The model fit was confirmed using Wald\u0026rsquo;s F(p)\u0026thinsp;=\u0026thinsp;2168.86 (p \u0026lt; .001) and R\u0026sup2; = 0.056.\u003c/p\u003e\n \u003cp\u003eNext, the direct effect of depression during the COVID-19 pandemic on suicidal ideation was examined using complex sample logistic regression analysis. Depression during COVID-19 was found to have a significant direct impact on suicidal ideation (B\u0026thinsp;=\u0026thinsp;1.28, SE\u0026thinsp;=\u0026thinsp;0.031, t\u0026thinsp;=\u0026thinsp;41.56, p \u0026lt; .001), with an odds ratio (OR) of 3.60 (95% CI: 3.388\u0026ndash;3.823). This suggests that an increase in depression during the COVID-19 pandemic was associated with a higher likelihood of suicidal ideation. The model fit was Wald F(p)\u0026thinsp;=\u0026thinsp;1727.00 (p \u0026lt; .001) and McFadden R\u0026sup2; = 0.075.\u003c/p\u003e\n \u003cp\u003eFinally, to test the mediating effects of anxiety, depression during COVID-19, and anxiety were simultaneously included in the model to predict suicidal ideation (Fig. \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The results demonstrated that depression (B\u0026thinsp;=\u0026thinsp;0.97, SE\u0026thinsp;=\u0026thinsp;0.031, t\u0026thinsp;=\u0026thinsp;31.09, p \u0026lt; .001) and anxiety (B\u0026thinsp;=\u0026thinsp;1.20, SE\u0026thinsp;=\u0026thinsp;0.023, t\u0026thinsp;=\u0026thinsp;52.97, p \u0026lt; .001) significantly influenced suicidal ideation. Anxiety partially mediated the relationship between depression during the COVID-19 pandemic and suicidal ideation, as confirmed by the Sobel test (Z\u0026thinsp;=\u0026thinsp;36.91, p \u0026lt; .001). The model fit was further supported by Wald\u0026rsquo;s F(p)\u0026thinsp;=\u0026thinsp;2370.493 (p \u0026lt; .001) and McFadden\u0026rsquo;s R\u0026sup2; = 0.147.\u003c/p\u003e\n \u003cp\u003eThe odds ratios (ORs) for depression and anxiety during the COVID-19 pandemic were 2.64 (95% CI: 2.486\u0026ndash;2.811) and 3.31 (95% CI: 3.166\u0026ndash;3.460), respectively. These findings indicate that a one-unit increase in depression during COVID-19 increases the likelihood of suicidal ideation by 2.64 times, while a one-unit increase in anxiety raises it by 3.31 times. These results highlight the critical mediating role of anxiety and emphasise the importance of addressing anxiety in interventions aimed at reducing suicidal ideation among adolescents.\u003c/p\u003e\n \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e\n \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. Moderation Analysis: Moderating Role of Loneliness in the Relationship Between Anxiety and Suicidal Ideation\u003c/h2\u003e\n \u003cp\u003eA complex sample logistic regression analysis was conducted to examine the moderating role of loneliness in the relationship between anxiety and suicidal ideation among adolescents (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eFirst, the impact of anxiety on suicidal ideation was analysed. The results revealed that anxiety (M) had a significant positive effect on suicidal ideation (Y) (B\u0026thinsp;=\u0026thinsp;1.42, SE\u0026thinsp;=\u0026thinsp;0.022, t\u0026thinsp;=\u0026thinsp;65.44, p \u0026lt; .001). Specifically, a one-unit increase in anxiety was associated with a 4.13-fold higher likelihood of suicidal ideation (95% CI: 3.958\u0026ndash;4.310). The model fit was confirmed using Wald\u0026rsquo;s F(p)\u0026thinsp;=\u0026thinsp;5501.75 (p \u0026lt; .001) and McFadden\u0026rsquo;s R\u0026sup2; = 0.159.\u003c/p\u003e\n \u003cp\u003eNext, we examined the effect of loneliness on suicidal ideation. The findings indicated that loneliness (V) also had a significant positive impact on suicidal ideation (B\u0026thinsp;=\u0026thinsp;1.44, SE\u0026thinsp;=\u0026thinsp;0.021, t\u0026thinsp;=\u0026thinsp;69.68, p \u0026lt; .001). A one-unit increase in loneliness corresponded to a 4.22-fold higher likelihood of suicidal ideation (95% CI, 4.051\u0026ndash;4.219). The model fit for this analysis was Wald F(p)\u0026thinsp;=\u0026thinsp;4855.40 (p \u0026lt; .001) and McFadden R\u0026sup2; = 0.158.\u003c/p\u003e\n \u003cp\u003eFinally, the interaction effect between anxiety and loneliness (M*V) on suicidal ideation was tested to determine whether loneliness moderated the relationship between anxiety and suicidal ideation (Fig. \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The results confirmed that the interaction term had a significantly positive effect on suicidal ideation (B\u0026thinsp;=\u0026thinsp;0.52, SE\u0026thinsp;=\u0026thinsp;0.008, t\u0026thinsp;=\u0026thinsp;68.50, p \u0026lt; .001). The odds ratio for the interaction effect was 1.68 (95% CI: 1.654\u0026ndash;1.679)\u0026mdash;a one-unit increase in the interaction between anxiety and loneliness increases the likelihood of suicidal ideation by 1.68 times. This finding highlights that loneliness serves as a critical moderating variable amplifying the relationship between anxiety and suicidal ideation. The model fit was Wald F(p)\u0026thinsp;=\u0026thinsp;4692.616 (p \u0026lt; .001) and McFadden R\u0026sup2; = 0.164.\u003c/p\u003e\n \u003cp\u003eOverall, the model fit indices show a progressive increase in McFadden R\u0026sup2; values across the three steps, from 0.159 in the first step to 0.164 in the final step. This incremental improvement underscores the importance of loneliness in the relationship between anxiety and suicide ideation. These results suggest that adolescents experiencing high levels of anxiety and loneliness are at a significantly greater risk of developing suicidal ideation, emphasising the need for targeted interventions addressing loneliness to mitigate this risk.\u003c/p\u003e\n \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here]\u003c/p\u003e\n \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study explored the complex pathways through which depression, anxiety, and loneliness influence suicidal ideation among adolescents during the COVID-19 pandemic. The findings demonstrated that COVID-19-related depression indirectly influenced suicidal ideation through anxiety and that loneliness moderated the relationship between anxiety and suicidal ideation. These results provide critical insights into adolescent mental health during social crises such as the pandemic and highlight the essential considerations for developing effective intervention strategies.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Mediating Relationship of Coronavirus Disease 2019-Related Depression, Anxiety, and Suicidal Ideation\u003c/h2\u003e \u003cp\u003eFirst, the results confirmed that COVID-19-related depression significantly impacted suicidal ideation directly and indirectly through anxiety. This finding suggests that depression increases the risk of suicidal ideation and amplifies anxiety, further exacerbating suicidal thoughts. Prior studies support these findings\u0026mdash;reducing depression can lower suicidal ideation by 24%, whereas addressing anxiety can lead to a 74% reduction in suicidal ideation (Metts et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdolescence is a developmental period characterised by a heightened vulnerability to anxiety, and reports have indicated a marked increase in anxiety disorders among adolescents during the pandemic (Foster et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kiviruusu et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Risk factors for adolescent anxiety during the pandemic included sex (women), remote learning, younger age, financial difficulties, and future (Jung et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Muzaffar et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Foster et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kiviruusu et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This study highlights the pivotal role of anxiety as a mechanism by which depression influences suicidal ideation, emphasising the need for integrated mental health strategies that address the interplay between these factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Moderating Role of Loneliness\u003c/h2\u003e \u003cp\u003eSecond, the study found that loneliness moderates the relationship between anxiety and suicidal ideation. While the existing research has primarily focused on the direct link between loneliness and suicidal ideation (Schinka et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Wang et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), this study identified a specific moderating role of loneliness in amplifying the impact of anxiety on suicidal ideation. Loneliness is an emotional state and a risk factor associated with negative thought patterns, substance abuse, sleep disturbances, and even increased mortality (Holt-Lunstad et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Masi et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Doane \u0026amp; Thurston \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; R\u0026ouml;nk\u0026auml; et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdolescents experience heightened loneliness during the pandemic due to prolonged social isolation (Thakur et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Research has suggested that the duration of loneliness, rather than its intensity, significantly affects mental health outcomes (Loades et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This underscores the importance of targeting loneliness in interventions aimed at enhancing adolescent mental health during periods of social isolation. Although family functioning and peer connections do not mitigate depression directly, they may alleviate loneliness, highlighting the importance of loneliness-focused interventions (Vacaru et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Interaction Among Depression, Anxiety, and Loneliness\u003c/h2\u003e \u003cp\u003eThird, loneliness significantly moderates the pathway through which COVID-19-related depression indirectly influences suicidal ideation through anxiety. Higher levels of loneliness had more potent indirect effects. This aligns with Liang\u0026rsquo;s (2023) findings that demonstrate the interdependent development of depression, social anxiety, and loneliness. This study further elaborates on these relationships by revealing their complex interactions in predicting suicidal ideation. The interpersonal-psychological theory of suicide identifies a lack of belongingness as a critical predictor of suicidal ideation (Ma et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). During the pandemic, an abrupt increase in social disconnection heightened loneliness, which amplified the risk of suicidal ideation. This finding emphasises the need to prioritise interventions addressing loneliness to prevent suicidal ideation during crises.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Implications and Limitations\u003c/h2\u003e \u003cp\u003eThis study provides important insights for the prevention of suicidal ideation in adolescents. Protective factors against loneliness, such as social support (McMahon et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), family connections (Al Omari et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), a sense of belonging (Joiner \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), and peer support (Pandey et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Aboagye et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), can significantly mitigate mental health challenges. However, research has shown that virtual interactions during the pandemic have not fully satisfied relational needs (McMahon et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and Gallagher (2014) noted that social support alone may be insufficient for suicide prevention. Therefore, it is critical to address the emotional aspects of loneliness. Mental health professionals should actively assess and intervene in adolescent loneliness during crises. Thus, innovative strategies for fostering belongingness, even in remote environments, are urgently required.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, it used cross-sectional data collected in 2020, limiting its ability to determine long-term causal relationships among the variables. Future longitudinal studies are necessary to examine these changes over time. Second, subjective bias may have influenced self-reported survey data, necessitating the inclusion of objective and multidimensional data collection methods. Third, the study focused on Korean adolescents, and further research is required to generalise the findings to other cultural contexts.\u003c/p\u003e \u003cp\u003eNevertheless, this study makes a significant contribution by empirically elucidating the complex interplay between depression, anxiety, loneliness, and suicidal ideation in the unique context of the COVID-19 pandemic. By integrating these psychological factors, our findings offer practical and evidence-based guidance for developing targeted intervention strategies to enhance adolescent mental health and prevent suicidal ideation during future social crises.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval statement:\u0026nbsp;\u003c/strong\u003eAll participants provided informed consent or assent. The Institutional Review Board of a university approved the study on 8 February 2024 (no. [Anonymized]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement:\u0026nbsp;\u003c/strong\u003eThis study was not obtained patient/parent/guardian consent because it is secondary data analysis research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information:\u0026nbsp;\u003c/strong\u003eThis work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (Grant no. RS-2023-NR076968).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eEC and YC wrote the main manuscript text and EC prepared figures and tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed in this study cannot be disclosed due to the protection of sensitive personal information regarding mental health, but they may be provided by the corresponding author upon request for reasonable purposes.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAboagye, R. G. et al. 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Differences in Suicidal Ideation According to General and Health-Related Characteristics of Adolescents \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN=54,848\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"611\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 131px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eSuicidal ideation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 112px;\"\u003e\n \u003cp\u003eRao-Scott \u0026nbsp; \u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNo (n=47,892)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;Yes (n= 6956)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e25,762\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,639\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e395.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e22,130\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4,317\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e26,047\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,968\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e12.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e21,845\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,988\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eEconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e19,139\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,429\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e218.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eMiddle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e23,892\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,185\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e4,861\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,342\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eEconomic changes during COVID-19\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e33,912\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4,224\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e284.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e13,980\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(83.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,732\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAcademic performance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e18,202\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,326\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e75.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eMiddle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e14,977\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,926\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e14,713\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,704\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eLiving with family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e45,902\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e6,524\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e47.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1,990\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e432\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eHealth status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e32,437\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,092\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e948.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e11,930\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,368\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePoor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e3,525\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(70.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,496\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e33,015\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(89.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,894\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e371.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e14,877\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,062\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e43,719\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(88.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e5,800\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e351.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e4,173\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,156\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e10,169\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(98.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e208\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2343.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e21,881\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(94.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,345\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e15,842\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e5,403\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eFatigue recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eEnough\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e11,934\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e905\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e501.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e16,176\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(90.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,735\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eInsufficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e19,782\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(82.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4,316\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eCOVID-19, Coronavirus disease 2019\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Differences in Suicidal Ideation According to Mental Health Characteristics of Adolescents \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN=54,848\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 131px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 87px;\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eSuicidal ideation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 112px;\"\u003e\n \u003cp\u003eRao-Scott \u0026nbsp; \u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNo (n=47,892)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;Yes (n= 6956)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 112px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eLoneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eAlmost none\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e25,346\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(96.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e975\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3225.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e17,306\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2,466\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e5,240\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3,515\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eAlmost none\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e44,075\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4,068\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3276.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e2,832\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,639\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e985\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,249\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eDepression during\u0026nbsp;\u003cbr\u003e\u0026nbsp; COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eDecrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e5,151\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e392\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1717.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eSimilar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e27,871\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(94.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1,691\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eIncrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e14,858\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4,872\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e(24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eCOVID-19, Coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eTable 3. Mediating Effects of Anxiety on Depression During Coronavirus Disease 2019 and Suicidal Ideation\u003c/p\u003e\n\u003cp\u003eN=54,848\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003eStep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 107px;\"\u003e\n \u003cp\u003eVariable\u0026nbsp;\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003eDependent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 48px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003et(p)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 63px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eLLCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003eULCI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eDepression during COVID-19 (X)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003e(M)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e46.57\u003c/p\u003e\n \u003cp\u003e(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e.168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.183\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eModel fit: Wald F(p) 2168.86 (\u0026lt;.001), R\u003csup\u003e2\u003c/sup\u003e(.056)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eDepression during COVID-19 (X)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003cp\u003e(Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e41.56 (\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e3.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3.388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eModel fit: Wald F(p) 1727.00 (\u0026lt;.001), McFadden R\u003csup\u003e2\u003c/sup\u003e(.075)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eDepression during COVID-19 (X)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003cp\u003e(Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e31.09 (\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e2.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2.811\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eAnxiety (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e52.97 (\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3.460\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eModel fit: Wald F(p) 2370.493 (\u0026lt;.001), McFadden R\u003csup\u003e2\u003c/sup\u003e(.147)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eSobel test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003e\u0026nbsp;Z=36.91 (\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eCOVID-19, Coronavirus disease 2019; B, coefficient; LLCI, lower limit confidence interval; M, mediate variable; OR, odds ratio; SE, standard error; ULCI, upper limit confidence interval; X, independent variable; Y, independent variable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Moderating Effects of Loneliness on Anxiety and Suicidal Ideation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN=54,848\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003eStep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 107px;\"\u003e\n \u003cp\u003eVariable\u0026nbsp;\u0026rarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003eDependent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 48px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003et(p)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 63px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eLLCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003eULCI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eAnxiety (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003cp\u003e(Y)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e65.44 (\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e4.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3.958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e4.310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eWald F(p) 5501.75(\u0026lt;.001), McFadden R\u003csup\u003e2\u003c/sup\u003e (.159)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eLoneliness (V)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003cp\u003e(Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e69.68\u003c/p\u003e\n \u003cp\u003e(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e4.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e4.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eWald F(p) 4855.40 (\u0026lt;.001), McFadden R\u003csup\u003e2\u003c/sup\u003e(.158)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eAnxiety*\u0026nbsp;Loneliness\u003c/p\u003e\n \u003cp\u003e(M*V)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSuicidal ideation\u003c/p\u003e\n \u003cp\u003e(Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e68.50\u003c/p\u003e\n \u003cp\u003e(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\n \u003cp\u003e1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e1.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1.654\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 521px;\"\u003e\n \u003cp\u003eWald F(p) 4692.616 (\u0026lt;.001), McFadden R\u003csup\u003e2\u003c/sup\u003e(.164)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u0026nbsp;\u003c/em\u003eB, coefficient; LLCI, lower limit confidence interval; OR, odds ratio; SE, standard error; ULCI, upper-limit confidence interval; V, moderated variable; X, independent variable; Y, independent variable.\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescence, Anxiety, Depression, Loneliness, Suicide","lastPublishedDoi":"10.21203/rs.3.rs-9343756/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9343756/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study investigated the mediating effect of anxiety and the moderating effect of loneliness on the relationship between depression during the coronavirus disease 2019 (COVID-19) pandemic and suicidal ideation among adolescents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were analysed from the 17th Korea Youth Risk Behavior Web-based Survey (KYRBS), a 2020 self-report survey targeting 54,848 middle and high school students in South Korea during the COVID-19 lockdown.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDepression had a significant direct effect on suicidal ideation and an indirect effect mediated by anxiety (B\u0026thinsp;=\u0026thinsp;1.28, p\u0026lt;.001; Sobel test Z\u0026thinsp;=\u0026thinsp;36.91, p\u0026lt;.001). A one-unit increase in depression raised the likelihood of suicidal ideation by 2.64 times (Odds Ratio [OR]\u0026thinsp;=\u0026thinsp;2.64, 95% CI: 2.486\u0026ndash;2.811), while anxiety increased the possibility by 3.31 times (OR\u0026thinsp;=\u0026thinsp;3.31, 95% CI: 3.166\u0026ndash;3.460). Loneliness significantly moderated the relationship between anxiety and suicidal ideation, with a one-unit increase in loneliness raising the odds by 4.22 times (OR\u0026thinsp;=\u0026thinsp;4.22, 95% CI: 4.051\u0026ndash;4.219). The interaction between anxiety and loneliness amplified the possibility by 1.68 times (OR\u0026thinsp;=\u0026thinsp;1.68, 95% CI: 1.654\u0026ndash;1.679).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese findings highlight the intricate interplay between depression, anxiety, and loneliness in influencing suicidal ideation among adolescents during the COVID-19 pandemic. Loneliness emerged as a critical factor moderating the relationship between anxiety and suicidal ideation. Early identification of anxiety and interventions aimed at alleviating loneliness as integral components of adolescent suicide prevention strategies, particularly during societal crises. Comprehensive intervention programs addressing these interconnected factors psychological factors are essential for improving adolescent mental health outcomes.\u003c/p\u003e","manuscriptTitle":"The Impact of Depression during COVID-19 on Suicidal Ideation in Adolescents: Anxiety as a Mediator and Loneliness as a Moderator","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 14:32:00","doi":"10.21203/rs.3.rs-9343756/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T06:19:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73780942706970372046526348003772608748","date":"2026-05-11T01:35:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18035194585605404433229871974669266502","date":"2026-05-07T09:23:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-07T07:32:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-07T07:23:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-22T04:55:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-10T00:03:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-04-09T23:59:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51388f51-cfd4-4c38-88de-7c6797535965","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T06:19:45+00:00","index":72,"fulltext":""},{"type":"reviewerAgreed","content":"73780942706970372046526348003772608748","date":"2026-05-11T01:35:31+00:00","index":71,"fulltext":""},{"type":"reviewerAgreed","content":"18035194585605404433229871974669266502","date":"2026-05-07T09:23:54+00:00","index":69,"fulltext":""},{"type":"reviewersInvited","content":"6","date":"2026-05-07T07:32:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-07T07:23:46+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":68191446,"name":"Health sciences/Diseases"},{"id":68191447,"name":"Health sciences/Health care"},{"id":68191448,"name":"Biological sciences/Psychology"},{"id":68191449,"name":"Social science/Psychology"},{"id":68191450,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-15T14:32:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 14:32:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9343756","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9343756","identity":"rs-9343756","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}