The Mediating Role of Major Depressive Symptoms on Academic Stress and Suicidal Ideation among School-going Adolescents in Manipur, India

The Mediating Role of Major Depressive Symptoms on Academic Stress and Suicidal Ideation among School-going Adolescents in Manipur, India | 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 Research Article The Mediating Role of Major Depressive Symptoms on Academic Stress and Suicidal Ideation among School-going Adolescents in Manipur, India Ravina Khumanlambam, Supa Pengpid, Mondha Kengganpanich, Karl Peltzer, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7004743/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Suicide is a major public health concern in India, with rising rates among adolescents. School-going adolescents are particularly vulnerable due to academic pressure and related mental health issues, especially depression. Objectives: While prior studies have examined the prevalence and individual predictors of suicidal ideation (SI), limited research has explored the mechanism linking academic stress (AS) to SI through major depressive symptoms (MDS), particularly in under-researched regions like Manipur, Northeast India. This study examines the associations between AS, MDS, and SI, and whether MDS mediates the relationship between AS and SI, adjusting for a range of socio-demographic factors. Methods: A cross-sectional study was conducted among 861 school-going adolescents (Grades 9–12) from six randomly selected schools in Imphal, Manipur, between August and October 2024. Data were collected using self-administered questionnaires, assessing AS (Educational Stress Scale for Adolescents [ESSA]), MDS (Patient Health Questionnaire-8 [PHQ-8]), and SI (Item 9 of the PHQ-A) and socio-demographics. Analyses included descriptive statistics, chi-square tests, logistic regression, and mediation analysis. Results: High AS (88.3%), positive for MDS (41.7%), and SI (43.9%) were prevalent. SI prevalence was significantly higher among students with high AS (47.5%) and MDS (69.4%). Logistic regression identified both AS (OR = 2.71) and MDS (OR = 5.49) as significant predictors of SI. Mediation analysis confirmed that AS predicted MDS (OR = 12.02), which in turn predicted SI, with a significant partial mediation effect. Causal mediation analysis revealed that 51% of AS’s total effect on SI was mediated through MDS (ACME = 0.125, p < 0.001). Conclusion: AS predicts SI directly and via MDS, indicating partial mediation. Findings advocate the need for early, school-based interventions targeting both AS and MDS, especially in high-risk regions like Manipur, Northeast India. Academic stress Major depressive symptoms Suicidal ideation adolescents Mediation analysis Figures Figure 5 Introduction Suicide, as characterized by the World Health Organization (WHO) as the intentional act of ending one's life [ 1 ] , remains a multifaceted and tragic public health issue globally [ 2 , 3 ] , with a suicide occurring every 40 seconds despite enhanced national prevention efforts [ 4 ] , and it is notably the third leading cause of death among adolescents, predominantly associated with undiagnosed depression [ 5 ] . With these alarming reports among youths, India, as the most populous nation globally, encompasses around 253 million adolescents aged 10–19 [ 6 ] , a demographic of significant importance for public health, as this developmental stage is marked by substantial physiological, psychological, and social changes, increasing susceptibility to emotional distress such as depression and suicidal thoughts or ideations [ 7 ] . National statistics substantiate this apprehension. The National Crime Records Bureau (NCRB) reported 170,924 suicides in India for 2022, reflecting a 4.2% rise from the preceding year, with 7.6% of these being students and 2,248 linked to academic failure [ 8 ] ; thus, academic stress emerges as a significant psychosocial risk factor for this demographic, as highlighted by The Lancet, which indicates India's highest global suicide rate among youth aged 15–29, primarily due to academic pressure [ 9 , 10 ] . Academic stress encompasses the anxiety and emotional turmoil stemming from academic pressures and expectations, with contributing factors including fear of failure, overwhelming workloads, high expectations from parents and institutions, and lack of interest in the curriculum [ 11 ] ; these stressors adversely influence students' academic performance and significantly correlate with depressive symptoms and suicidal ideation [ 12 ] . Academic stress can trigger a series of psychological processes that elevate the risk of depression and suicidal thoughts. Academic stress originates from multiple factors, such as excessive homework, elevated expectations from educators and parents, fear of failure, and disinterest in subjects [ 11 – 13 ] . Depressive symptoms, typically evaluated through instruments like the PHQ-9 or PHQ-A, include enduring sadness, reduced interest, fatigue, concentration difficulties, low self-esteem, and suicidal ideation; concurrently, academic stress may catalyze cognitive distortions such as perfectionism and catastrophizing, which correlate with feelings of hopelessness and helplessness [ 14 , 15 ] . As for suicidal ideation, it encompasses thoughts or an unusual focus on suicide, varying from transient thoughts to comprehensive planning [ 16 ] . Depressive symptoms or depression is the known precursors to suicide risk and thereby exacerbating psychological distress that hinders emotional regulation and fosters maladaptive coping mechanisms, including substance abuse, ultimately deteriorating mental health outcomes such as depression and heighten the risk of suicidal ideation. [ 17 – 19 ] . A systematic review of 52 studies indicated a positive association between academic pressure and depression and suicidal ideation [ 20 ] . In India, systemic pressures within the educational framework, particularly in Grades 11 and 12 where high-stakes examinations dictate higher education access, exacerbate issues [ 21 ] ; a Kolkata study indicated that over 63% of students experience academic stress [ 22 ] , while research from Belagavi city found that 68% endure moderate to severe depression, with 15% having contemplated suicidal thoughts [ 12 ] . The Northeast region of India, especially Manipur, confronts a severe mental health crisis exacerbated by political instability, ethnic discord, economic deprivation, and insufficient mental health resources [ 23 ] , with the National Mental Health Survey (2015–16) indicating that Manipur exhibits the highest prevalence of mental disorders (13.9%) and the second highest suicide risk (10.3%) among the Indian states surveyed [ 24 ] . While previous international research (for instance, from Singapore and Korea) indicates that depression mediates the link of academic stress and suicidal ideation and suicidal behavior [ 25 , 26 ] , empirical research on this topic among Indian adolescents is limited, even as issues like suicide, depression, and academic stress increase. This gap is particularly significant in conflict-affected and underrepresented regions like Manipur, Northeast India, where adolescents encounter heightened mental morbidity such as depression and stress, and suicide risks. Addressing this gap, the present study examines the mediating effect of major depressive symptoms on the relationship between academic stress and suicidal ideation in adolescents in Manipur. The study employed both logistic regression–based mediation analysis and the Average Causal Mediation Effect (ACME) framework, while controlling for key sociodemographic variables such as gender, age, religion, grade, academic performance, family type, residence, number of siblings, parental education, and socioeconomic status. to yield detailed, context-specific insights. These findings aim to guide early identification methods and school-based mental health initiatives. Methods Data and Methods The research employed a cross-sectional survey design. Setting This research was carried out in urban private schools in Imphal, Manipur, India, focusing on adolescents aged 13 to 18 years. Data collection occurred from August 2024 to October 2024. Sample and Procedure ( Fig. 1 ) : Participants were eligible for inclusion in the study if they were aged 13 to 18 years, enrolled full-time in grades 9 to 12 (2024-25 academic year) in Imphal East or West districts, and provided assent with parental consent. Exclusion criteria included a prior psychiatric diagnosis, current physical or mental illness, ongoing psychological or psychiatric treatment, absence during the survey, incomplete or invalid questionnaire responses (defined as > 20% missing data), or refusal/withdrawal of assent or parental consent at any stage of participation. Calculation of sample size was done utilizing Epi Info version 7.2.2.6 software. According to the 2023-24 census, the total population of Grade 9–12 students in private schools of Imphal (East and West district) was 30,690 [ 27 , 28 ] . The estimated prevalence of mental health issues, as measured by the DASS, among Higher Secondary School students in Manipur was approximately 34.7% according to a study conducted in 2014 [ 17 ] . A sample size of 594 was determined in a study conducted in Imphal, Manipur. The potential for discontinuing participation in the study was considered, resulting in a projected 20% loss of participants, leading to a final sample size of 743. Approximately 902 students exhibited voluntary participation. Following data cleaning, 861 students were included in the final analysis (Fig. 1 ). Measures Participants filled out the self-administered Educational Stress Scale for Adolescents (ESSA), the Patient Health Questionnaire (PHQ-8), and Item 9 of the PHQ-A and provided socio-demographic information. Before administering the surveys to research participants, the instruments underwent pre-testing in a similar environment (n = 30) to assess their appropriateness and demonstrated high reliability for adolescents in Manipur, India (Cronbach’s α = 0.89 for ESSA and 0.74 for PHQ-A). 1. Educational Stress Scale for Adolescents (ESSA) ESSA consists of 16 items designed to evaluate educational stress across five dimensions: study pressure (4 items), workload (3 items), concern about grades (3 items), self-expectation (3 items), and despondency (3 items) [ 29 ] . Responses are evaluated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), where higher scores indicate greater academic stress (AS). Scores range from 16 to 80. The ESSA total score was categorized into three levels: low stress levels (0–21), medium (22–42), and high (43–64), consistent with a study conducted in Malaysia among school-going adolescents in 2022 [ 30 ] . Authorization to use this tool was granted by one of the developers and authors, Michael Dunne. The Cronbach’s alpha for ESSA among East Asian adolescents was 0.81, demonstrating good internal consistency. The Cronbach’s alpha for ESSA in this study (n = 861) was 0.818, consistent with the findings of Sun et al. in 2013 [ 29 ] . This study utilized the adapted version of the PHQ-9, known as PHQ-A (Physical Health Questionnaire for Adolescents), which employs a four-point Likert scale to assess the severity of depressive symptoms. This tool is available at no cost. Responses are categorized on a 4-point scale, with 0 indicating 'not at all' and 3 representing 'nearly every day.' The PHQ-9 demonstrated strong internal consistency among Indian adolescents, with a Cronbach's α of .835. The Cronbach's alpha for the PHQ-A in this study was 0.823. A threshold score of ≥ 10 on the PHQ-9 exhibited substantial concordance with diagnoses according to the International Classification of Diseases, 10th Revision (Cohen's κ = .62) [ 10 ] . Therefore, in this study, participants were categorized into presence and absence of major depressive symptoms (MDS). A score of ≥ 10 on the PHQ-A was deemed elevated and categorized as MDS in this study [ 31 – 34 ] . 2. Major Depressive Symptoms (PHQ-8 from PHQ-A) Major depressive symptoms were evaluated using the Patient Health Questionnaire–Adolescent version (PHQ-A), a validated adolescent adaptation [ 35 ] of the PHQ-9 [ 33 ] , which employs a four-point Likert scale to assess the severity of depressive symptoms. Responses are categorized on a 4-point scale, with 0 indicating 'not at all' and 3 representing 'nearly every day.' The PHQ-9 exhibits robust internal consistency among Indian adolescents (Cronbach's α = .835) [ 10 ] . The PHQ-9 demonstrated strong internal consistency among Indian adolescents, with a Cronbach's α of .835 [ 10 ] . To prevent overlap with suicidal ideation, Item 9 was omitted, leading to the utilization of the PHQ-8 in this research for major depressive symptom assessment. A score of ≥ 10 on the PHQ-8 signifies clinically significant depressive symptoms per established criteria. PHQ-8 was therefore used to assess Major Depressive Symptoms (MDS) [ 36 , 37 ] . This approach is supported by evidence showing near-perfect correlation between PHQ-8 and PHQ-9 (r = 0.996) [ 37 ] and comparable diagnostic accuracy (sensitivity = 58.3%, specificity = 83.1%) [ 38 ] . Removing Item 9 has minimal impact on diagnostic performance while reducing false positives related to suicide risk [ 37 , 39 ] . In this study, the PHQ-8 showed strong internal consistency (α = 0.823) and was highly correlated with PHQ-A scores (r = 0.99, p < .001), justifying its separate use in mediation analyses. 3. Suicidal Ideation (PHQ-A Item 9) SI was measured using Item 9 of the PHQ-A: “Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Responses range from 0 (“not at all”) to 3 (“nearly every day”). SI was coded as present if the score was ≥ 1 indicating its presence [ 40 , 41 ] , following established adolescent research [ 42 ] . Item 9 effectively stratifies suicide attempt risk among adolescents [ 43 , 44 ] and was analyzed independently to preserve construct clarity and avoid confounding with depressive symptom scores in the mediation model. 4. Instrument Reliability and Pretesting All instruments were pretested in a similar sample of 30 adolescents to assess contextual appropriateness and internal consistency. Cronbach’s alpha was 0.89 for ESSA and 0.74 for PHQ-A in the pilot sample. Final internal consistency values in the main study were α = 0.818 for ESSA and α = 0.823 for PHQ-A, indicating strong reliability in this adolescent population. Statistical methods Data analysis was conducted using IBM SPSS version 26.0 (IBM Corp.) Descriptive statistics outlined participant characteristics and report the prevalence of academic stress (AS), major depressive symptoms (MDS), and suicidal ideation (SI), while chi-square tests evaluated bivariate relationships among AS, MDS, and SI. A multivariable logistic regression was employed to explore the independent impacts of academic stress and MDS on SI, while controlling for gender, age, religion, grade, academic performance, family type, residence, number of siblings, parental education, and socioeconomic status. Mediation analysis was performed using logistic regression pathways (paths a, b, and c′) and the Average Causal Mediation Effect (ACME) framework to ascertain the indirect (ACME), direct (ADE), and total influences of AS on SI through MDS, with all models adjusted for identical covariates. Before administering the surveys to research participants, the instruments underwent pretesting in a similar environment to assess their appropriateness. Results Participants The study sample consisted of 861 students from grades 9 to 12. Of the total participants, 43% (n = 370) were male students, while 57% (n = 491) were female students. The mean age was 15.56 years, with a standard deviation of ± 1.23, for the age range of 13 to 18 years. Most participants were from urban hometowns (63.6%, n = 548) compared to rural areas (36.4%, n = 313). Prevalence of SI : Around 43.9% (n = 378) reported presence of some level of SI (ranging from “several days” to “nearly every day”). 13.4% reported to have SI nearly every day (n = 116). The overall mean of SI was found to be 0.8, SD ± 1.08 (Fig. 2 , Table 1 ) Table 1 Frequency Distribution of SI, MDS and AS (N = 861) Variable Category/Level Range Frequency (n) Percentage (%) Suicidal Ideation No SI (PHQ-A Item 9 = 0) 0–1 483 56.1 SI present (Score ≥ 1) 378 43.9 Major Depressive Symptoms No MDD (PHQ-A < 10) 0–1 502 58.3 MDD Present (PHQ-A ≥ 10) 359 41.7 Academic Stress Low (ESSA score 0–21) 1–3 0 0 Moderate (ESSA score 22–42) 101 11.7 High (ESSA score 43–64) 760 88.3 Footnotes : • Suicidal Ideation: A score ≥ 1 on Item 9 indicates any level of suicidal thoughts, including infrequent or passive ideation (“several days” or more). Prevalence of MDS : Around 41.7% (n = 359) reported the presence of MDS while 58.3% (n = 502) did not. The mean of MDS was found to be 0.42, SD ± 0.493 (Fig. 3 , Table 1 ) Prevalence of AS : Around 88.2% (n = 760) reported the presence of high AS and remaining 11.7% with moderate AS (n = 101). There were absence of any students reporting to have low AS (0%, n = 0) The overall mean of AS was found to be 02.88, SD ± 0.32 (Fig. 4 , Table 1 ). Chi square and Logistic regression Chi-square analyses revealed strong and statistically significant associations between suicidal ideation (SI) and both academic stress (AS) and major depressive symptoms (MDS). Specifically, SI was reported by 47.5% of students experiencing high academic stress compared to 16.8% of those with moderate stress (χ² = 32.81, p < 0.001). Similarly, 69.4% of students with major depressive symptoms reported SI, in contrast to 25.7% of those without MDS (χ² = 160.25, p < 0.001), underscoring the strong relationship between depressive symptoms and suicidal ideation (see Table 2 ). Table 2 Association Between AS, MDS and SI Variable χ² Value P value SI Prevalence (%) Academic Stress (High vs Medium) 32.81 < 0.001 47.5% vs 16.8% Major Depressive Symptoms (Yes vs No) 160.25 < 0.001 69.4% vs 25.7% Footnotes : • Percentages reflect SI prevalence within groups. • Associations are significant at p < 0.001. Multivariable Logistic Regression Results ( Fig. 5 , Table 3 ) Table 3 Multivariable Logistic regression analysis of factors associated with SI, controlling for sociodemographic variables Variable OR 95% CI p-value Intercept 0.095 0.032–0.278 < 0.001 Academic Stress (AS) 2.583 1.442–4.627 0.001 Major Depressive Symptoms (MDS) 5.576 4.055–7.666 < 0.001 Gender 1.389 1.011–1.908 0.043 Hometown 0.72 0.516–1.001 0.050 Age 0.858 0.550–1.338 0.498 Academic Performance 1.552 1.073–2.244 0.020 Standard/ Grade 1.017 0.651–1.590 0.941 Family Type 1.165 0.850–1.596 0.343 Number of Siblings 1.179 1.014–1.372 0.033 Residence 0.779 0.486–1.249 0.300 Father's Education 1.039 0.925–1.167 0.523 Mother's Education 0.946 0.853–1.049 0.290 Socioeconomic Status 1.240 0.560–2.746 0.596 Footnotes : • Estimates are presented as odds ratios (OR) with corresponding 95% confidence intervals (CI) and p -values. • OR > 1 indicates increased odds of SI, while OR < 1 indicates decreased odds. • Significant predictors at p < 0.05 include Academic Stress, Major Depressive Symptoms, Female Gender, Rural Hometown (protective), Academic Performance, and Number of Siblings. • Other variables such as Age, Religion, Grade, Family Type, Residence, Parental Education, and Socioeconomic Status showed no significant association with SI in this model. A multivariable logistic regression analysis was conducted to examine the independent associations between suicidal ideation (SI) and a range of predictor variables including academic stress (AS), major depressive symptoms (MDS), gender, age, academic performance, grade level, family type, number of siblings, residence type, parental education, and socioeconomic status among school-going adolescents. MDS emerged as the strongest independent predictor of SI. Adolescents who screened positive for MDS had more than five times the odds of reporting SI than those without such symptoms (OR = 5.58, 95% CI: 4.06–7.67, p < 0.001). High AS was also a significant predictor. Students experiencing high levels of AS had more than twice the odds of SI compared to those with lower AS levels (OR = 2.58, 95% CI: 1.44–4.63, p = 0.001). Gender showed a significant association, with female students having higher odds of SI than males (OR = 1.39, 95% CI: 1.01–1.91, p = 0.043). Hometown demonstrated marginal significance. Students from rural areas had lower odds of SI than their urban counterparts (OR = 0.72, 95% CI: 0.52–1.00, p = 0.05). Academic Performance, measured as a binary variable (medium vs. higher), was significantly associated with SI. Students with lower academic performance were more likely to report SI (OR = 1.55, 95% CI: 1.07–2.24, p = 0.020). Number of Siblings showed a positive association. Each additional sibling was associated with an increase in the odds of SI (OR = 1.18, 95% CI: 1.01–1.37, p = 0.033). Other sociodemographic variables including age ( p = 0.498), grade ( p = 0.941), family type ( p = 0.343), residence status ( p = 0.300), mother’s education ( p = 0.523), father’s education ( p = 0.290), and socioeconomic status ( p = 0.596) were not significantly associated with SI in the adjusted model. These discoveries emphasize the complex nature of SI in adolescents, with MDS and AS, assuming essential roles, in conjunction with specific sociodemographic factors. Mediation Analysis (Fig. 6 ) This section presents the findings from two complementary mediation models examining how major depressive symptoms (MDS) mediate the relationship between academic stress (AS) and suicidal ideation (SI) among adolescents while adjusting for various socio-demographic factors: (a) a logistic regression-based mediation model, and (b) a causal mediation model based on the Average Causal Mediation Effect (ACME) framework. (a) Logistic Regression-Based Mediation Analysis ( Table 4 ) Table 4 Logistic regression-based mediation analysis examining the indirect and direct effects of AS on SI via MDS Path Effect Type Coefficient Std. Error OR 95% CI (OR) p-value AS → MDS (a) Indirect 2.486 0.412 12.02 5.74–29.49 < 0.001 MDS → SI (b) Indirect 1.704 0.171 5.49 3.94–7.71 < 0.001 AS → SI (c′) Direct 0.995 0.313 2.71 1.50–5.16 0.001 Footnotes : • Path a represents the effect of academic stress (AS) on major depressive symptoms (MDS) • Path b represents the effect of MDS on suicidal ideation (SI) • Path c′ denotes the direct effect of AS on SI after controlling for MDS. • All coefficients are in log-odds; OR = Odds Ratio; CI = Confidence Interval. • All effects are statistically significant at p < 0.01. • The mediation model is adjusted for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, father’s and mother’s education, and socioeconomic status. A stepwise logistic regression mediation model was employed to assess the direct and indirect effects of AS on SI through MDS, adjusting for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, parental education, and socioeconomic status. Path a (AS → MDS): AS significantly predicted MDS (coefficient = 2.486, OR = 12.02, 95% CI [5.74, 29.49], p < 0.001), indicating that students experiencing high AS were over 12 times more likely to report MDS, Path b (MDS → SI): MDS were a strong and significant predictor of SI (coefficient = 1.704, OR = 5.49, 95% CI [3.94, 7.71], p < 0.001), suggesting that students with MDS had over 5 times the odds of reporting SI. Path c′ (AS → SI, controlling for MDS): The direct effect of AS on SI remained significant even after accounting for MDS (coefficient = 0.995, OR = 2.71, 95% CI [1.50, 5.16], p = 0.001), indicating partial mediation. This implies that AS independently contributes to SI, beyond its indirect effect through MDS. (b) Causal Mediation Analysis Using the ACME Framework ( Table 5 ) Table 5 Causal mediation analysis of the effect of academic stress on suicidal ideation through major depressive symptoms (ACME and ADE estimates) Effect Estimate 95% CI p-value Meaning ACME (avg.) 0.125 0.088–0.160 < 0.001 The indirect (mediated) effect is significant. ADE (avg.) 0.119 0.054–0.190 < 0.001 The direct effect is also significant. Total Effect 0.244 0.174–0.310 < 0.001 There is a significant total effect of the exposure on the outcome. Prop. Mediated (avg.) 0.513 0.353–0.710 < 0.001 About 51% of the total effect is explained via the mediator. Footnotes : • Path a represents the effect of AS on MDS, and Path b represents the effect of MDS on SI. • ACME quantifies the indirect (mediated) effect of AS on SI through MDS. • ADE denotes the direct effect of AS on SI, independent of MDS. • The Total Effect is the sum of ACME and ADE. • Proportion Mediated reflects the percentage of the total effect of AS on SI that is explained by MDS. • Confidence intervals (CI) and p-values indicate statistical significance, with ACME and ADE both significant at p < 0.001, suggesting partial but meaningful mediation. • The mediation model is adjusted for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, father’s and mother’s education, and socioeconomic status. To quantify the mediation effect and estimate the proportion mediated, causal mediation analysis was performed using the Average Causal Mediation Effect (ACME) framework, adjusting for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, parental education, and socioeconomic status. This approach facilitates stronger inferences regarding counterfactual assumptions. Path a (AS → MDS): AS was a strong positive predictor of MDS (estimate = 2.486, p < 0.001), indicating that adolescents experiencing high AS were significantly more likely to report MDS. Path b (MDS → SI): MDS, in turn, were significantly associated with SI (estimate = 1.704, p < 0.001), suggesting that adolescents with MDS were substantially more likely to experience SI. Path c′ (AS → SI, controlling for MDS): The direct effect of AS on SI remained significant even after accounting for MDS (estimate = 0.955, p = 0.001), indicating partial mediation. This suggests that AS contributes to S independently of its effect through MDS. Average Causal Mediation Effect (ACME): The indirect effect of AS on SI through MDS was statistically significant (ACME = 0.125, 95% CI [0.088, 0.160], p < 0.001), supporting the presence of a meaningful mediating pathway. Average Direct Effect (ADE): The direct effect of AS on SI remained significant even after accounting for MDS (ADE = 0.119, 95% CI [0.054, 0.190], p < 0.001), indicating a substantial independent contribution. Total Effect: The overall effect of AS on S was significant (Total Effect = 0.244, 95% CI [0.174, 0.310], p < 0.001), confirming AS as a notable risk factor. Proportion Mediated: Approximately 51.3% of the total effect was mediated by MDS (Proportion Mediated = 0.513, 95% CI [0.353, 0.710], p < 0.001), highlighting MDS as a significant pathway through which AS influences SI. These findings highlight the psychological mechanism by which AS contributes to SI and confirm that MDS serve as a key mediator in this pathway. However, the persistence of a significant direct effect also suggests that other unmeasured factors such as hopelessness, low self-worth, or family-related stressors may additionally influence the development of SI. Moreover, it is noteworthy that the Educational Stress Scale for Adolescents (ESSA) used to measure AS comprises five dimensions: pressure from study, workload, worry about grades, self-expectation, and despondency. These domains may variably contribute to students’ psychological distress and thus account for the remaining direct effects observed in the model DISCUSSION This study contributes to a growing body of evidence highlighting the critical role of academic stress and depressive symptoms in the development of suicidal ideation among adolescents in Manipur, India. Our findings revealed a high prevalence of depressive symptoms and suicidal ideation, consistent with national and regional patterns. According to the NCRB (2022), suicide among Indian students continues to rise [ 45 ] , with academic pressure and mental disorders identified as a major contributing factor [ 46 , 47 ] . Prior research similarly identifies academic stress as a leading psychological risk factor for adolescent suicide [ 48 – 50 ] . In our sample, high academic stress significantly increased the odds of suicidal ideation (OR = 2.71, p < .001), aligning with evidence that elevated academic demands, performance anxiety, and fear of failure can lead to emotional dysregulation and suicidal ideation or thoughts [ 26 , 51 ] . Consistent with existing literature [ 52 , 53 ] , academic stress was also positively associated with depressive symptoms. Adolescents facing intense academic expectations often internalize feelings of inadequacy and hopelessness, resulting in heightened vulnerability to depression. In our study, MDS (measured by PHQ-A) was not only highly prevalent but also a strong predictor of SI, with students scoring above the clinical threshold (PHQ-A ≥ 10) having 17.19 times higher odds of SI ( p < .001). These findings reinforce existing evidence that depression is a primary affective disorder underlying adolescent suicide risk [ 54 , 55 ] . The mediation analysis in our study offers further insight into this pathway. Depressive symptoms significantly mediated the relationship between academic stress and suicidal ideation, suggesting that academic stress contributes to suicidal ideation indirectly through the development of depressive symptoms. This supports earlier mediation models reported in Singapore and Korea [ 26 , 56 , 57 ] and highlights the importance of early screening and intervention for depressive symptoms among students exposed to academic stress. Theoretical frameworks such as the Differential Activation Theory of Suicidality also support this mechanism, positing that negative self-concepts and hopelessness arising from depression increase suicide risk [ 54 ] . In terms of socio-demographic predictors, gender, hometown and number of siblings emerged as significant factors. Female students reported significantly higher rates of both depressive symptoms and suicidal ideation compared to males, a finding consistent with previous research [ 58 , 59 ] . The pervasive societal stigma and insufficient support mechanisms for women confronting suicidal ideation frequently result in a culture of secrecy and underreporting, thereby exacerbating the complexity of the issue [ 60 ] . This may reflect gender differences in emotional regulation, internalizing behaviors, and socio-cultural norms such as stigma around help-seeking and academic pressures [ 58 ] . Moreover, in many Asian contexts, social taboos and gender norms can increase women’s vulnerability to depression due to systemic restrictions, societal expectations, and discrimination [ 61 ] . However, on the other hand, the mortality rate on a global scale from suicide was recorded at 12.6 per 100,000 for males and 5.4 per 100,000 for females [ 62 ] . Although some studies show that suicidal ideation and attempts were found to be more among females than males, however, some studies indicate that females report higher rates of suicidal ideation, the actual frequency of suicide attempts does not significantly differ between genders. This suggests that greater suicidal thoughts in females do not necessarily translate into more attempts compared to males [ 63 ] . Urban adolescents reported higher rates of suicidal ideation than their rural counterparts, supporting the hypothesis that urban environments, while offering greater access to educational and healthcare resources may also expose adolescents to increased academic competition, social isolation, and pressure for achievement [ 64 , 65 ] . In contrast, the slower-paced lifestyle and community-based protective factors in rural settings may buffer against suicidal ideation, but not for completed suicides, This is likely due to greater access to lethal means and mental health service access remains limited [ 66 , 67 ] . While previous studies have not directly linked number of siblings to suicidal ideation, they have associated larger family size with increased mental health concerns or depressive symptoms, often due to resource dilution and perceived parental differential treatment [ 68 , 69 ] . Our finding shows a significant association between sibling number and suicidal ideation (OR = 1.20, 95% CI: 1.03–1.40, p = 0.017) suggesting that these dynamics may also contribute to suicide risk. Conversely, warm and supportive sibling relationships have been shown to reduce the risk of depression [ 69 ] . Academic performance serves as a crucial indicator of suicidal ideation among adolescents as found in this study. Earlier studies also showed that low academic performance heightens the likelihood of suicide attempts (OR = 1.48) [ 70 ] and concerns regarding scholastic performance are correlated with suicidal thoughts or ideation, although social support can mitigate this rs [ 71 ] . Even after controlling for socioeconomic variables, inadequate academic performance persists as an independent correlate of suicidal ideation [ 72 ] . It was found that postve academic self-concept, especially within alternative educational environments, may contribute to the attenuation of this risk [ 73 ] . The other socio-demographic factors such as age, grade/standard, and socio-economic status were not found to be significant predictors of suicidal ideation or depressive symptoms in our multivariate models. This suggests that subjective experiences of stress and psychological distress may have a stronger impact than objective performance indicators, echoing findings that academic expectations and perceived failure may exert greater emotional toll than actual grades [ 22 , 74 ] . CONCLUSION This study reveals a high prevalence of academic stress (88.3%), major depressive symptoms (41.7%), and suicidal ideation (43.9%) among adolescents in Imphal, Manipur. Crucially, depressive symptoms mediate the relationship between academic stress and suicidal ideation, highlighting the importance of early identification and intervention. There is a clear need for school-based mental health programs focused on literacy, stress management, and depression screening. Evidence supports the effectiveness of mindfulness practices [ 75 ] , emotion regulation strategies [ 76 ] , and peer/social support [ 77 ] in reducing depressive symptoms and suicidal thoughts. Given that improvements in depression often precede reductions in suicidal ideation [ 78 ] , addressing depression should be a priority. Routine screening has proven both accurate [ 79 ] and beneficial in reducing crisis outcomes [ 80 ] . Integrating evidence-based interventions into schools is essential to prevent the escalation from academic stress to suicidal behavior in Indian adolescents. Limitations and Future Directions This study is limited by its focus on SI, which may not reflect the experiences of those who attempt or die by suicide. Future research should examine suicide attempts for a more comprehensive understanding of risk factors. Additionally, self-reported data may be subject to response biases. The research was carried out in urban educational institutions in Imphal, thereby constraining the applicability of the results to rural demographics or different areas within India. Even though logistic regression accounted for potential confounding variables, the cross-sectional nature of the study still constrains any inferences regarding causality among AS, MDS, and SI. Although essential sociodemographic variables were incorporated into the model, other unobserved factors such as peer support, history of trauma, or substance use could also affect SI and were not addressed in this examination. Future longitudinal studies are warranted to explore the dynamic relationship between academic stress, depression, and suicidal ideation over time, particularly in under-researched and high-burden regions such as Northeast India. Abbreviations SI Suicidal Ideation MDS Major Depressive Symptoms AS Academic Stress PHQ-A Patient Health Questionnaire- Adolescents PHQ-8 Patient Health Questionnaire- 8 ESSA Educational Stress Scale for Adolescents ACME Average Causal Mediation Effect ADE Average Direct Effect Declarations Ethics approval and consent to participate Ethical Ethical approval for the study was obtained from the Mahidol University Institutional Review Board (IRB) (COA. No. MUPH 2024-063) and the Research Ethics Board (REB), Regional Institute of Medical Sciences, Imphal (Registration No. A/206/REB/Prop (Sp)226/202/18/2024) in accordance with the Declaration of Helsinki. Consent and assent from informed parents and students were obtained. To ensure participant privacy, an anonymous approach was utilized. Following the survey, students identified as requiring urgent mental health assistance, including those exhibiting major depressive symptoms or suicidal ideation, were promptly referred for professional help or counselling. Consent for publication Not applicable Availability of data and material The data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they possess no identifiable competing interests. Funding None Authors' contributions RK : Writing – review & editing, Writing – original draft, Visualization, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. SP: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. MK: Writing – review & editing, Validation, Supervision, Project administration, Investigation. KP: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. RLS: Writing – review & editing, Validation, Supervision, Project administration, Resources, Investigation. Acknowledgements The researchers acknowledge the students for their participation, the schools for their support, and the parents and guardians for their consent and the students for their assent. References World Health Organization. Preventing suicide: A global imperative.; 2014. World Health Organization. Suicide rates-World Health Statistics 2020 visual summary. 2020. Snowdon J, Choi NG. Undercounting of suicides: Where suicide data lie hidden. Glob Public Health. 2020;15(12):1894-901. World Health Organization. Suicide in the world: global health estimates. Geneva; 2019. World Health Organization. Suicide: World Health Organization; 2025 [Available from: https://www.who.int/news-room/fact-sheets/detail/suicide. 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Adolescent suicidal ideation: dissecting the role of sex in depression and NSSI predictors. Child Adolesc Psychiatry Ment Health. 2024;18(1):68. Wasil A, Gillespie S, Park S, DeRubeis R. Not all depressive symptoms matter equally: Ratings of the relative importance of nine DSM symptoms in a sample of Indian adolescents2021. Patel A, Dixon KE, Rojas S, Gopalakrishnan L, Carmio N. Explaining Suicide Among Indian Women: Applying the Cultural Theory of Suicide to Indian Survivors of Gender-Based Violence Reporting Suicidal Ideation. J Interpers Violence. 2025;40(3-4):658-80. Prasla M. Adolescence Depression in Pakistan: A New Horizon for Research. J Pak Med Stud. 2012;2(4). Al-Huseini S, Al maqbali M, Mirza H, Al Khatri M, Al Saadi A, Chan M-F, et al. Prevalence and associated factors of a repeat of suicide attempt among individuals attending an emergency department in Oman. Discov Psychol. 2024;4(1):181. Campisi SC, Carducci B, Akseer N, Zasowski C, Szatmari P, Bhutta ZA. 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Temporal relationships between changes in depression and suicidal ideation: A mediation analysis in a randomized double-blinded clinical trial. Psychol Psychother. 2023;96(2):364-82. Viswanathan M, Wallace IF, Cook Middleton J, Kennedy SM, McKeeman J, Hudson K, et al. Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;328(15):1543-56. Adeyeye S. Improved Monitoring of Depression and Suicidal Ideation in Low-Income Adolescents through Evidenced Based Provider Education: University of San Diego; 2022. 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-7004743","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481868247,"identity":"f7c4d26c-9066-45d5-9260-f53848f25d83","order_by":0,"name":"Ravina 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Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rajkumar","middleName":"Lenin","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2025-06-29 20:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7004743/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7004743/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24901-8","type":"published","date":"2025-11-04T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86643335,"identity":"c1a65e3e-9745-4012-a8df-ee1a3893395d","added_by":"auto","created_at":"2025-07-14 08:36:14","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":50956,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdjusted Odds Ratios (with 95% CI) for Sociodemographic Predictors of Suicidal Ideation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFootnotes:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cem\u003eOdds ratios are presented on a log scale.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cem\u003eReference categories: Male (for Gender), Urban (for Hometown), 0 siblings (for Number of Siblings), and \"Low\" (for Academic Performance).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7004743/v1/14fe0bbf6d4fcbd11880289f.jpg"},{"id":95563935,"identity":"d129bed8-1a46-4afb-9a8c-d1b4c7e0c07c","added_by":"auto","created_at":"2025-11-10 16:04:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1249022,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7004743/v1/b4f666a7-801f-4564-b8d9-138ee2ddb9d5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Mediating Role of Major Depressive Symptoms on Academic Stress and Suicidal Ideation among School-going Adolescents in Manipur, India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuicide, as characterized by the World Health Organization (WHO) as the intentional act of ending one's life \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, remains a multifaceted and tragic public health issue globally \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, with a suicide occurring every 40 seconds despite enhanced national prevention efforts \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, and it is notably the third leading cause of death among adolescents, predominantly associated with undiagnosed depression \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. With these alarming reports among youths, India, as the most populous nation globally, encompasses around 253\u0026nbsp;million adolescents aged 10–19 \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, a demographic of significant importance for public health, as this developmental stage is marked by substantial physiological, psychological, and social changes, increasing susceptibility to emotional distress such as depression and suicidal thoughts or ideations \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eNational statistics substantiate this apprehension. The National Crime Records Bureau (NCRB) reported 170,924 suicides in India for 2022, reflecting a 4.2% rise from the preceding year, with 7.6% of these being students and 2,248 linked to academic failure \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e; thus, academic stress emerges as a significant psychosocial risk factor for this demographic, as highlighted by The Lancet, which indicates India's highest global suicide rate among youth aged 15–29, primarily due to academic pressure \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAcademic stress encompasses the anxiety and emotional turmoil stemming from academic pressures and expectations, with contributing factors including fear of failure, overwhelming workloads, high expectations from parents and institutions, and lack of interest in the curriculum \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e; these stressors adversely influence students' academic performance and significantly correlate with depressive symptoms and suicidal ideation \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Academic stress can trigger a series of psychological processes that elevate the risk of depression and suicidal thoughts. Academic stress originates from multiple factors, such as excessive homework, elevated expectations from educators and parents, fear of failure, and disinterest in subjects \u003csup\u003e[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDepressive symptoms, typically evaluated through instruments like the PHQ-9 or PHQ-A, include enduring sadness, reduced interest, fatigue, concentration difficulties, low self-esteem, and suicidal ideation; concurrently, academic stress may catalyze cognitive distortions such as perfectionism and catastrophizing, which correlate with feelings of hopelessness and helplessness\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. As for suicidal ideation, it encompasses thoughts or an unusual focus on suicide, varying from transient thoughts to comprehensive planning \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Depressive symptoms or depression is the known precursors to suicide risk and thereby exacerbating psychological distress that hinders emotional regulation and fosters maladaptive coping mechanisms, including substance abuse, ultimately deteriorating mental health outcomes such as depression and heighten the risk of suicidal ideation. \u003csup\u003e[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e–\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. A systematic review of 52 studies indicated a positive association between academic pressure and depression and suicidal ideation \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In India, systemic pressures within the educational framework, particularly in Grades 11 and 12 where high-stakes examinations dictate higher education access, exacerbate issues \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e; a Kolkata study indicated that over 63% of students experience academic stress \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e, while research from Belagavi city found that 68% endure moderate to severe depression, with 15% having contemplated suicidal thoughts \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe Northeast region of India, especially Manipur, confronts a severe mental health crisis exacerbated by political instability, ethnic discord, economic deprivation, and insufficient mental health resources \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, with the National Mental Health Survey (2015–16) indicating that Manipur exhibits the highest prevalence of mental disorders (13.9%) and the second highest suicide risk (10.3%) among the Indian states surveyed \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. While previous international research (for instance, from Singapore and Korea) indicates that depression mediates the link of academic stress and suicidal ideation and suicidal behavior \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, empirical research on this topic among Indian adolescents is limited, even as issues like suicide, depression, and academic stress increase. This gap is particularly significant in conflict-affected and underrepresented regions like Manipur, Northeast India, where adolescents encounter heightened mental morbidity such as depression and stress, and suicide risks. Addressing this gap, the present study examines the mediating effect of major depressive symptoms on the relationship between academic stress and suicidal ideation in adolescents in Manipur. The study employed both logistic regression–based mediation analysis and the Average Causal Mediation Effect (ACME) framework, while controlling for key sociodemographic variables such as gender, age, religion, grade, academic performance, family type, residence, number of siblings, parental education, and socioeconomic status. to yield detailed, context-specific insights. These findings aim to guide early identification methods and school-based mental health initiatives.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eData and Methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe research employed a cross-sectional survey design.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis research was carried out in urban private schools in Imphal, Manipur, India, focusing on adolescents aged 13 to 18 years. Data collection occurred from August 2024 to October 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample and Procedure (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eParticipants were eligible for inclusion in the study if they were aged 13 to 18 years, enrolled full-time in grades 9 to 12 (2024-25 academic year) in Imphal East or West districts, and provided assent with parental consent. Exclusion criteria included a prior psychiatric diagnosis, current physical or mental illness, ongoing psychological or psychiatric treatment, absence during the survey, incomplete or invalid questionnaire responses (defined as \u0026gt; 20% missing data), or refusal/withdrawal of assent or parental consent at any stage of participation.\u003c/p\u003e\u003cp\u003eCalculation of sample size was done utilizing Epi Info version 7.2.2.6 software. According to the 2023-24 census, the total population of Grade 9–12 students in private schools of Imphal (East and West district) was 30,690 \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. The estimated prevalence of mental health issues, as measured by the DASS, among Higher Secondary School students in Manipur was approximately 34.7% according to a study conducted in 2014\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. A sample size of 594 was determined in a study conducted in Imphal, Manipur. The potential for discontinuing participation in the study was considered, resulting in a projected 20% loss of participants, leading to a final sample size of 743. Approximately 902 students exhibited voluntary participation. Following data cleaning, 861 students were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants filled out the self-administered Educational Stress Scale for Adolescents (ESSA), the Patient Health Questionnaire (PHQ-8), and Item 9 of the PHQ-A and provided socio-demographic information. Before administering the surveys to research participants, the instruments underwent pre-testing in a similar environment (n = 30) to assess their appropriateness and demonstrated high reliability for adolescents in Manipur, India (Cronbach’s α = 0.89 for ESSA and 0.74 for PHQ-A).\u003c/p\u003e\u003cp\u003e\u003cb\u003e1. Educational Stress Scale for Adolescents (ESSA)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eESSA consists of 16 items designed to evaluate educational stress across five dimensions: study pressure (4 items), workload (3 items), concern about grades (3 items), self-expectation (3 items), and despondency (3 items)\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Responses are evaluated using a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), where higher scores indicate greater academic stress (AS). Scores range from 16 to 80. The ESSA total score was categorized into three levels: low stress levels (0–21), medium (22–42), and high (43–64), consistent with a study conducted in Malaysia among school-going adolescents in 2022 \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Authorization to use this tool was granted by one of the developers and authors, Michael Dunne. The Cronbach’s alpha for ESSA among East Asian adolescents was 0.81, demonstrating good internal consistency. The Cronbach’s alpha for ESSA in this study (n = 861) was 0.818, consistent with the findings of Sun et al. in 2013 \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study utilized the adapted version of the PHQ-9, known as PHQ-A (Physical Health Questionnaire for Adolescents), which employs a four-point Likert scale to assess the severity of depressive symptoms. This tool is available at no cost. Responses are categorized on a 4-point scale, with 0 indicating 'not at all' and 3 representing 'nearly every day.' The PHQ-9 demonstrated strong internal consistency among Indian adolescents, with a Cronbach's α of .835. The Cronbach's alpha for the PHQ-A in this study was 0.823. A threshold score of ≥ 10 on the PHQ-9 exhibited substantial concordance with diagnoses according to the International Classification of Diseases, 10th Revision (Cohen's κ = .62) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Therefore, in this study, participants were categorized into presence and absence of major depressive symptoms (MDS). A score of ≥ 10 on the PHQ-A was deemed elevated and categorized as MDS in this study \u003csup\u003e[\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e–\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Major Depressive Symptoms (PHQ-8 from PHQ-A)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMajor depressive symptoms were evaluated using the Patient Health Questionnaire–Adolescent version (PHQ-A), a validated adolescent adaptation \u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e of the PHQ-9\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e, which employs a four-point Likert scale to assess the severity of depressive symptoms. Responses are categorized on a 4-point scale, with 0 indicating 'not at all' and 3 representing 'nearly every day.' The PHQ-9 exhibits robust internal consistency among Indian adolescents (Cronbach's α = .835) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. The PHQ-9 demonstrated strong internal consistency among Indian adolescents, with a Cronbach's α of .835 \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo prevent overlap with suicidal ideation, Item 9 was omitted, leading to the utilization of the PHQ-8 in this research for major depressive symptom assessment. A score of ≥ 10 on the PHQ-8 signifies clinically significant depressive symptoms per established criteria. PHQ-8 was therefore used to assess Major Depressive Symptoms (MDS) \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. This approach is supported by evidence showing near-perfect correlation between PHQ-8 and PHQ-9 (r = 0.996)\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e and comparable diagnostic accuracy (sensitivity = 58.3%, specificity = 83.1%) \u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Removing Item 9 has minimal impact on diagnostic performance while reducing false positives related to suicide risk \u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. In this study, the PHQ-8 showed strong internal consistency (α = 0.823) and was highly correlated with PHQ-A scores (r = 0.99, p \u0026lt; .001), justifying its separate use in mediation analyses.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3. Suicidal Ideation (PHQ-A Item 9)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSI was measured using Item 9 of the PHQ-A: \u003cem\u003e“Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”\u003c/em\u003e Responses range from 0 (“not at all”) to 3 (“nearly every day”). SI was coded as present if the score was ≥ 1 indicating its presence \u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e, following established adolescent research \u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. Item 9 effectively stratifies suicide attempt risk among adolescents \u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e and was analyzed independently to preserve construct clarity and avoid confounding with depressive symptom scores in the mediation model.\u003c/p\u003e\u003cp\u003e\u003cb\u003e4. Instrument Reliability and Pretesting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll instruments were pretested in a similar sample of 30 adolescents to assess contextual appropriateness and internal consistency. Cronbach’s alpha was 0.89 for ESSA and 0.74 for PHQ-A in the pilot sample. Final internal consistency values in the main study were α = 0.818 for ESSA and α = 0.823 for PHQ-A, indicating strong reliability in this adolescent population.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData analysis was conducted using IBM SPSS version 26.0 (IBM Corp.) Descriptive statistics outlined participant characteristics and report the prevalence of academic stress (AS), major depressive symptoms (MDS), and suicidal ideation (SI), while chi-square tests evaluated bivariate relationships among AS, MDS, and SI. A multivariable logistic regression was employed to explore the independent impacts of academic stress and MDS on SI, while controlling for gender, age, religion, grade, academic performance, family type, residence, number of siblings, parental education, and socioeconomic status. Mediation analysis was performed using logistic regression pathways (paths a, b, and c′) and the Average Causal Mediation Effect (ACME) framework to ascertain the indirect (ACME), direct (ADE), and total influences of AS on SI through MDS, with all models adjusted for identical covariates. Before administering the surveys to research participants, the instruments underwent pretesting in a similar environment to assess their appropriateness.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study sample consisted of 861 students from grades 9 to 12. Of the total participants, 43% (n\u0026thinsp;=\u0026thinsp;370) were male students, while 57% (n\u0026thinsp;=\u0026thinsp;491) were female students. The mean age was 15.56 years, with a standard deviation of \u0026plusmn;\u0026thinsp;1.23, for the age range of 13 to 18 years. Most participants were from urban hometowns (63.6%, n\u0026thinsp;=\u0026thinsp;548) compared to rural areas (36.4%, n\u0026thinsp;=\u0026thinsp;313).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence of SI\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAround 43.9% (n\u0026thinsp;=\u0026thinsp;378) reported presence of some level of SI (ranging from \u0026ldquo;several days\u0026rdquo; to \u0026ldquo;nearly every day\u0026rdquo;). 13.4% reported to have SI nearly every day (n\u0026thinsp;=\u0026thinsp;116). The overall mean of SI was found to be 0.8, SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency Distribution of SI, MDS and AS (N\u0026thinsp;=\u0026thinsp;861)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory/Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003cp\u003e(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSuicidal Ideation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo SI (PHQ-A Item 9\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e483\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSI present (Score\u0026thinsp;\u0026ge;\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMajor Depressive Symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo MDD (PHQ-A\u0026thinsp;\u0026lt;\u0026thinsp;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e502\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMDD Present (PHQ-A\u0026thinsp;\u0026ge;\u0026thinsp;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAcademic Stress\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow (ESSA score 0\u0026ndash;21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate (ESSA score 22\u0026ndash;42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh (ESSA score 43\u0026ndash;64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e760\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Suicidal Ideation: A score\u0026thinsp;\u0026ge;\u0026thinsp;1 on Item 9 indicates any level of suicidal thoughts, including infrequent or passive ideation (\u0026ldquo;several days\u0026rdquo; or more).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence of MDS\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAround 41.7% (n\u0026thinsp;=\u0026thinsp;359) reported the presence of MDS while 58.3% (n\u0026thinsp;=\u0026thinsp;502) did not. The mean of MDS was found to be 0.42, SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.493 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence of AS\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAround 88.2% (n\u0026thinsp;=\u0026thinsp;760) reported the presence of high AS and remaining 11.7% with moderate AS (n\u0026thinsp;=\u0026thinsp;101). There were absence of any students reporting to have low AS (0%, n\u0026thinsp;=\u0026thinsp;0) The overall mean of AS was found to be 02.88, SD\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eChi square and Logistic regression\u003c/b\u003e\u003c/p\u003e\u003cp\u003eChi-square analyses revealed strong and statistically significant associations between suicidal ideation (SI) and both academic stress (AS) and major depressive symptoms (MDS). Specifically, SI was reported by 47.5% of students experiencing high academic stress compared to 16.8% of those with moderate stress (χ\u0026sup2; = 32.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, 69.4% of students with major depressive symptoms reported SI, in contrast to 25.7% of those without MDS (χ\u0026sup2; = 160.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), underscoring the strong relationship between depressive symptoms and suicidal ideation (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation Between AS, MDS and SI\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eχ\u0026sup2; Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSI Prevalence (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Stress (High vs Medium)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47.5% vs 16.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor Depressive Symptoms (Yes vs No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e160.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69.4% vs 25.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; Percentages reflect SI prevalence within groups.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; Associations are significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMultivariable Logistic Regression Results (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMultivariable Logistic regression analysis of factors associated with SI, controlling for sociodemographic variables\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntercept\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.032\u0026ndash;0.278\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Stress (AS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.583\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.442\u0026ndash;4.627\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor Depressive Symptoms (MDS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.055\u0026ndash;7.666\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.011\u0026ndash;1.908\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHometown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.516\u0026ndash;1.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.050\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.858\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.550\u0026ndash;1.338\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.498\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.073\u0026ndash;2.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStandard/ Grade\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.651\u0026ndash;1.590\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.941\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.850\u0026ndash;1.596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.343\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Siblings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.014\u0026ndash;1.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.779\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.486\u0026ndash;1.249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.300\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFather's Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.925\u0026ndash;1.167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.523\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother's Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.946\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.853\u0026ndash;1.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.290\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocioeconomic Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.560\u0026ndash;2.746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; Estimates are presented as odds ratios (OR) with corresponding 95% confidence intervals (CI) and \u003cem\u003ep\u003c/em\u003e-values.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; OR\u0026thinsp;\u0026gt;\u0026thinsp;1 indicates increased odds of SI, while OR\u0026thinsp;\u0026lt;\u0026thinsp;1 indicates decreased odds.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; Significant predictors at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 include Academic Stress, Major Depressive Symptoms, Female Gender, Rural Hometown (protective), Academic Performance, and Number of Siblings.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026bull; Other variables such as Age, Religion, Grade, Family Type, Residence, Parental Education, and Socioeconomic Status showed no significant association with SI in this model.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA multivariable logistic regression analysis was conducted to examine the independent associations between suicidal ideation (SI) and a range of predictor variables including academic stress (AS), major depressive symptoms (MDS), gender, age, academic performance, grade level, family type, number of siblings, residence type, parental education, and socioeconomic status among school-going adolescents.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMDS emerged as the strongest independent predictor of SI. Adolescents who screened positive for MDS had more than five times the odds of reporting SI than those without such symptoms (OR\u0026thinsp;=\u0026thinsp;5.58, 95% CI: 4.06\u0026ndash;7.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHigh AS was also a significant predictor. Students experiencing high levels of AS had more than twice the odds of SI compared to those with lower AS levels (OR\u0026thinsp;=\u0026thinsp;2.58, 95% CI: 1.44\u0026ndash;4.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGender showed a significant association, with female students having higher odds of SI than males (OR\u0026thinsp;=\u0026thinsp;1.39, 95% CI: 1.01\u0026ndash;1.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHometown demonstrated marginal significance. Students from rural areas had lower odds of SI than their urban counterparts (OR\u0026thinsp;=\u0026thinsp;0.72, 95% CI: 0.52\u0026ndash;1.00, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAcademic Performance, measured as a binary variable (medium vs. higher), was significantly associated with SI. Students with lower academic performance were more likely to report SI (OR\u0026thinsp;=\u0026thinsp;1.55, 95% CI: 1.07\u0026ndash;2.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of Siblings showed a positive association. Each additional sibling was associated with an increase in the odds of SI (OR\u0026thinsp;=\u0026thinsp;1.18, 95% CI: 1.01\u0026ndash;1.37, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOther sociodemographic variables including age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.498), grade (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.941), family type (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.343), residence status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.300), mother\u0026rsquo;s education (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.523), father\u0026rsquo;s education (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.290), and socioeconomic status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.596) were not significantly associated with SI in the adjusted model.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThese discoveries emphasize the complex nature of SI in adolescents, with MDS and AS, assuming essential roles, in conjunction with specific sociodemographic factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMediation Analysis\u003c/b\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis section presents the findings from two complementary mediation models examining how major depressive symptoms (MDS) mediate the relationship between academic stress (AS) and suicidal ideation (SI) among adolescents while adjusting for various socio-demographic factors:\u003c/p\u003e\u003cp\u003e\u003cem\u003e(a) a logistic regression-based mediation model, and\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(b) a causal mediation model based on the Average Causal Mediation Effect (ACME) framework.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(a) Logistic Regression-Based Mediation Analysis (\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eLogistic regression-based mediation analysis examining the indirect and direct effects of AS on SI via MDS\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffect Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStd. Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI (OR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAS \u0026rarr; MDS (a)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndirect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.486\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.412\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.74\u0026ndash;29.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMDS \u0026rarr; SI (b)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndirect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.94\u0026ndash;7.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAS \u0026rarr; SI (c\u0026prime;)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.995\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.50\u0026ndash;5.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; Path a represents the effect of academic stress (AS) on major depressive symptoms (MDS)\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; Path b represents the effect of MDS on suicidal ideation (SI)\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; Path c\u0026prime; denotes the direct effect of AS on SI after controlling for MDS.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; All coefficients are in log-odds; OR\u0026thinsp;=\u0026thinsp;Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; All effects are statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026bull; The mediation model is adjusted for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, father\u0026rsquo;s and mother\u0026rsquo;s education, and socioeconomic status.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA stepwise logistic regression mediation model was employed to assess the direct and indirect effects of AS on SI through MDS, adjusting for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, parental education, and socioeconomic status.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePath a (AS \u0026rarr; MDS): AS significantly predicted MDS (coefficient\u0026thinsp;=\u0026thinsp;2.486, OR\u0026thinsp;=\u0026thinsp;12.02, 95% CI [5.74, 29.49], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that students experiencing high AS were over 12 times more likely to report MDS,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePath b (MDS \u0026rarr; SI): MDS were a strong and significant predictor of SI (coefficient\u0026thinsp;=\u0026thinsp;1.704, OR\u0026thinsp;=\u0026thinsp;5.49, 95% CI [3.94, 7.71], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting that students with MDS had over 5 times the odds of reporting SI.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePath c\u0026prime; (AS \u0026rarr; SI, controlling for MDS): The direct effect of AS on SI remained significant even after accounting for MDS (coefficient\u0026thinsp;=\u0026thinsp;0.995, OR\u0026thinsp;=\u0026thinsp;2.71, 95% CI [1.50, 5.16], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), indicating partial mediation. This implies that AS independently contributes to SI, beyond its indirect effect through MDS.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(b) Causal Mediation Analysis Using the ACME Framework (\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCausal mediation analysis of the effect of academic stress on suicidal ideation through major depressive symptoms (ACME and ADE estimates)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMeaning\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eACME (avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.088\u0026ndash;0.160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThe indirect (mediated) effect is significant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eADE (avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.054\u0026ndash;0.190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThe direct effect is also significant.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.174\u0026ndash;0.310\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThere is a significant total effect of the exposure on the outcome.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProp. Mediated (avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.353\u0026ndash;0.710\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAbout 51% of the total effect is explained via the mediator.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Path a represents the effect of AS on MDS, and Path b represents the effect of MDS on SI.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; ACME quantifies the indirect (mediated) effect of AS on SI through MDS.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; ADE denotes the direct effect of AS on SI, independent of MDS.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; The Total Effect is the sum of ACME and ADE.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Proportion Mediated reflects the percentage of the total effect of AS on SI that is explained by MDS.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; Confidence intervals (CI) and p-values indicate statistical significance, with ACME and ADE both significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, suggesting partial but meaningful mediation.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026bull; The mediation model is adjusted for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, father\u0026rsquo;s and mother\u0026rsquo;s education, and socioeconomic status.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo quantify the mediation effect and estimate the proportion mediated, causal mediation analysis was performed using the Average Causal Mediation Effect (ACME) framework, adjusting for gender, age, religion, grade, academic performance, hometown, family type, number of siblings, residence type, parental education, and socioeconomic status. This approach facilitates stronger inferences regarding counterfactual assumptions.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePath a (AS \u0026rarr; MDS): AS was a strong positive predictor of MDS (estimate\u0026thinsp;=\u0026thinsp;2.486, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that adolescents experiencing high AS were significantly more likely to report MDS.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePath b (MDS \u0026rarr; SI): MDS, in turn, were significantly associated with SI (estimate\u0026thinsp;=\u0026thinsp;1.704, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting that adolescents with MDS were substantially more likely to experience SI.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePath c\u0026prime; (AS \u0026rarr; SI, controlling for MDS): The direct effect of AS on SI remained significant even after accounting for MDS (estimate\u0026thinsp;=\u0026thinsp;0.955, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), indicating partial mediation. This suggests that AS contributes to S independently of its effect through MDS.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAverage Causal Mediation Effect (ACME): The indirect effect of AS on SI through MDS was statistically significant (ACME\u0026thinsp;=\u0026thinsp;0.125, 95% CI [0.088, 0.160], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), supporting the presence of a meaningful mediating pathway.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAverage Direct Effect (ADE): The direct effect of AS on SI remained significant even after accounting for MDS (ADE\u0026thinsp;=\u0026thinsp;0.119, 95% CI [0.054, 0.190], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a substantial independent contribution.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTotal Effect: The overall effect of AS on S was significant (Total Effect\u0026thinsp;=\u0026thinsp;0.244, 95% CI [0.174, 0.310], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming AS as a notable risk factor.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProportion Mediated: Approximately 51.3% of the total effect was mediated by MDS (Proportion Mediated\u0026thinsp;=\u0026thinsp;0.513, 95% CI [0.353, 0.710], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), highlighting MDS as a significant pathway through which AS influences SI.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThese findings highlight the psychological mechanism by which AS contributes to SI and confirm that MDS serve as a key mediator in this pathway. However, the persistence of a significant direct effect also suggests that other unmeasured factors such as hopelessness, low self-worth, or family-related stressors may additionally influence the development of SI.\u003c/p\u003e\u003cp\u003eMoreover, it is noteworthy that the Educational Stress Scale for Adolescents (ESSA) used to measure AS comprises five dimensions: pressure from study, workload, worry about grades, self-expectation, and despondency. These domains may variably contribute to students\u0026rsquo; psychological distress and thus account for the remaining direct effects observed in the model\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study contributes to a growing body of evidence highlighting the critical role of academic stress and depressive symptoms in the development of suicidal ideation among adolescents in Manipur, India. Our findings revealed a high prevalence of depressive symptoms and suicidal ideation, consistent with national and regional patterns. According to the NCRB (2022), suicide among Indian students continues to rise \u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e, with academic pressure and mental disorders identified as a major contributing factor \u003csup\u003e[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/sup\u003e. Prior research similarly identifies academic stress as a leading psychological risk factor for adolescent suicide \u003csup\u003e[\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/sup\u003e. In our sample, high academic stress significantly increased the odds of suicidal ideation (OR\u0026thinsp;=\u0026thinsp;2.71, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), aligning with evidence that elevated academic demands, performance anxiety, and fear of failure can lead to emotional dysregulation and suicidal ideation or thoughts \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eConsistent with existing literature\u003csup\u003e[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/sup\u003e, academic stress was also positively associated with depressive symptoms. Adolescents facing intense academic expectations often internalize feelings of inadequacy and hopelessness, resulting in heightened vulnerability to depression. In our study, MDS (measured by PHQ-A) was not only highly prevalent but also a strong predictor of SI, with students scoring above the clinical threshold (PHQ-A\u0026thinsp;\u0026ge;\u0026thinsp;10) having 17.19 times higher odds of SI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). These findings reinforce existing evidence that depression is a primary affective disorder underlying adolescent suicide risk \u003csup\u003e[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe mediation analysis in our study offers further insight into this pathway. Depressive symptoms significantly mediated the relationship between academic stress and suicidal ideation, suggesting that academic stress contributes to suicidal ideation indirectly through the development of depressive symptoms. This supports earlier mediation models reported in Singapore and Korea \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/sup\u003e and highlights the importance of early screening and intervention for depressive symptoms among students exposed to academic stress. Theoretical frameworks such as the Differential Activation Theory of Suicidality also support this mechanism, positing that negative self-concepts and hopelessness arising from depression increase suicide risk \u003csup\u003e[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn terms of socio-demographic predictors, gender, hometown and number of siblings emerged as significant factors. Female students reported significantly higher rates of both depressive symptoms and suicidal ideation compared to males, a finding consistent with previous research\u003csup\u003e[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/sup\u003e. The pervasive societal stigma and insufficient support mechanisms for women confronting suicidal ideation frequently result in a culture of secrecy and underreporting, thereby exacerbating the complexity of the issue \u003csup\u003e[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]\u003c/sup\u003e. This may reflect gender differences in emotional regulation, internalizing behaviors, and socio-cultural norms such as stigma around help-seeking and academic pressures \u003csup\u003e[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]\u003c/sup\u003e. Moreover, in many Asian contexts, social taboos and gender norms can increase women\u0026rsquo;s vulnerability to depression due to systemic restrictions, societal expectations, and discrimination\u003csup\u003e[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, on the other hand, the mortality rate on a global scale from suicide was recorded at 12.6 per 100,000 for males and 5.4 per 100,000 for females\u003csup\u003e[\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/sup\u003e. Although some studies show that suicidal ideation and attempts were found to be more among females than males, however, some studies indicate that females report higher rates of suicidal ideation, the actual frequency of suicide attempts does not significantly differ between genders. This suggests that greater suicidal thoughts in females do not necessarily translate into more attempts compared to males \u003csup\u003e[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eUrban adolescents reported higher rates of suicidal ideation than their rural counterparts, supporting the hypothesis that urban environments, while offering greater access to educational and healthcare resources may also expose adolescents to increased academic competition, social isolation, and pressure for achievement \u003csup\u003e[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/sup\u003e. In contrast, the slower-paced lifestyle and community-based protective factors in rural settings may buffer against suicidal ideation, but not for completed suicides, This is likely due to greater access to lethal means and mental health service access remains limited \u003csup\u003e[\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWhile previous studies have not directly linked number of siblings to suicidal ideation, they have associated larger family size with increased mental health concerns or depressive symptoms, often due to resource dilution and perceived parental differential treatment \u003csup\u003e[\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/sup\u003e. Our finding shows a significant association between sibling number and suicidal ideation (OR\u0026thinsp;=\u0026thinsp;1.20, 95% CI: 1.03\u0026ndash;1.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017) suggesting that these dynamics may also contribute to suicide risk. Conversely, warm and supportive sibling relationships have been shown to reduce the risk of depression \u003csup\u003e[\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAcademic performance serves as a crucial indicator of suicidal ideation among adolescents as found in this study. Earlier studies also showed that low academic performance heightens the likelihood of suicide attempts (OR\u0026thinsp;=\u0026thinsp;1.48) \u003csup\u003e[\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/sup\u003e and concerns regarding scholastic performance are correlated with suicidal thoughts or ideation, although social support can mitigate this rs \u003csup\u003e[\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]\u003c/sup\u003e. Even after controlling for socioeconomic variables, inadequate academic performance persists as an independent correlate of suicidal ideation \u003csup\u003e[\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]\u003c/sup\u003e. It was found that postve academic self-concept, especially within alternative educational environments, may contribute to the attenuation of this risk \u003csup\u003e[\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe other socio-demographic factors such as age, grade/standard, and socio-economic status were not found to be significant predictors of suicidal ideation or depressive symptoms in our multivariate models. This suggests that subjective experiences of stress and psychological distress may have a stronger impact than objective performance indicators, echoing findings that academic expectations and perceived failure may exert greater emotional toll than actual grades\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study reveals a high prevalence of academic stress (88.3%), major depressive symptoms (41.7%), and suicidal ideation (43.9%) among adolescents in Imphal, Manipur. Crucially, depressive symptoms mediate the relationship between academic stress and suicidal ideation, highlighting the importance of early identification and intervention.\u003c/p\u003e\u003cp\u003eThere is a clear need for school-based mental health programs focused on literacy, stress management, and depression screening. Evidence supports the effectiveness of mindfulness practices \u003csup\u003e[\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]\u003c/sup\u003e, emotion regulation strategies \u003csup\u003e[\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/sup\u003e, and peer/social support \u003csup\u003e[\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]\u003c/sup\u003e in reducing depressive symptoms and suicidal thoughts.\u003c/p\u003e\u003cp\u003eGiven that improvements in depression often precede reductions in suicidal ideation \u003csup\u003e[\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]\u003c/sup\u003e, addressing depression should be a priority. Routine screening has proven both accurate \u003csup\u003e[\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]\u003c/sup\u003e and beneficial in reducing crisis outcomes \u003csup\u003e[\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]\u003c/sup\u003e. Integrating evidence-based interventions into schools is essential to prevent the escalation from academic stress to suicidal behavior in Indian adolescents.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Future Directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study is limited by its focus on SI, which may not reflect the experiences of those who attempt or die by suicide. Future research should examine suicide attempts for a more comprehensive understanding of risk factors. Additionally, self-reported data may be subject to response biases. The research was carried out in urban educational institutions in Imphal, thereby constraining the applicability of the results to rural demographics or different areas within India. Even though logistic regression accounted for potential confounding variables, the cross-sectional nature of the study still constrains any inferences regarding causality among AS, MDS, and SI. Although essential sociodemographic variables were incorporated into the model, other unobserved factors such as peer support, history of trauma, or substance use could also affect SI and were not addressed in this examination. Future longitudinal studies are warranted to explore the dynamic relationship between academic stress, depression, and suicidal ideation over time, particularly in under-researched and high-burden regions such as Northeast India.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSuicidal Ideation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMDS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMajor Depressive Symptoms\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcademic Stress\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePHQ-A\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Health Questionnaire- Adolescents\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePHQ-8\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Health Questionnaire- 8\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eESSA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEducational Stress Scale for Adolescents\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eACME\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAverage Causal Mediation Effect\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eADE\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAverage Direct Effect\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical Ethical approval for the study was obtained from the Mahidol University Institutional Review Board (IRB) (COA. No. MUPH 2024-063) and the Research Ethics Board (REB), Regional Institute of Medical Sciences, Imphal (Registration No. A/206/REB/Prop (Sp)226/202/18/2024) in accordance with the Declaration of Helsinki. Consent and assent from informed parents and students were obtained. To ensure participant privacy, an anonymous approach was utilized. Following the survey, students identified as requiring urgent mental health assistance, including those exhibiting major depressive symptoms or suicidal ideation, were promptly referred for professional help or counselling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they possess no identifiable competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRK\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Writing – review \u0026amp; editing, Writing – original draft, Visualization, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. \u003cstrong\u003eSP:\u003c/strong\u003e Writing – review \u0026amp; editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. \u003cstrong\u003eMK:\u003c/strong\u003e Writing – review \u0026amp; editing, Validation, Supervision, Project administration, Investigation. \u003cstrong\u003eKP:\u003c/strong\u003e Writing – review \u0026amp; editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. \u003cstrong\u003eRLS:\u003c/strong\u003e Writing – review \u0026amp; editing, Validation, Supervision, Project administration, Resources, Investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers acknowledge the students for their participation, the schools for their support, and the parents and guardians for their consent and the students for their assent.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. 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School performance and the risk of suicidal thoughts in young adults: population-based study. PLoS One. 2014;9(10):e109958.\u003c/li\u003e\n\u003cli\u003eSzlyk HS. Suicidal Ideation among Youths at Risk of School Dropout: Impact of Student Demographics, Stressors, and Academic Self-Concept. Health Soc Work. 2021;45(4):240-8.\u003c/li\u003e\n\u003cli\u003eJayanthi P, Thirunavukarasu M, Rajkumar R. Academic stress and depression among adolescents: a cross-sectional study. Indian Pediatr. 2015;52(3):217-9.\u003c/li\u003e\n\u003cli\u003eAnastasiades MH, Kapoor S, Wootten J, Lamis DA. Perceived stress, depressive symptoms, and suicidal ideation in undergraduate women with varying levels of mindfulness. Arch Women\u0026apos;s Ment Health. 2017;20(1):129-38.\u003c/li\u003e\n\u003cli\u003eM\u0026eacute;rida-L\u0026oacute;pez S, Cirenia Q-O, A. PK, Consolaci\u0026oacute;n P-G, and Extremera N. Knowing is half the battle: Regulating and appraising emotions co-protect from suicidal ideation. Death Stud. 2024;48(6):621-9.\u003c/li\u003e\n\u003cli\u003eZhang X, Liu X, Mi Y, Wang W, Xu H. Resilience and Depressive Symptoms Mediated Pathways from Social Support to Suicidal Ideation Among Undergraduates During the COVID-19 Campus Lockdown in China. Psychol Res Behav Manag. 2022;15:2291-301.\u003c/li\u003e\n\u003cli\u003eShaygan M, Hosseini FA, Negad SS. Temporal relationships between changes in depression and suicidal ideation: A mediation analysis in a randomized double-blinded clinical trial. Psychol Psychother. 2023;96(2):364-82.\u003c/li\u003e\n\u003cli\u003eViswanathan M, Wallace IF, Cook Middleton J, Kennedy SM, McKeeman J, Hudson K, et al. Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;328(15):1543-56.\u003c/li\u003e\n\u003cli\u003eAdeyeye S. Improved Monitoring of Depression and Suicidal Ideation in Low-Income Adolescents through Evidenced Based Provider Education: University of San Diego; 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Academic stress, Major depressive symptoms, Suicidal ideation, adolescents, Mediation analysis","lastPublishedDoi":"10.21203/rs.3.rs-7004743/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7004743/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eSuicide is a major public health concern in India, with rising rates among adolescents. School-going adolescents are particularly vulnerable due to academic pressure and related mental health issues, especially depression.\u003c/p\u003e\u003ch2\u003eObjectives:\u003c/h2\u003e\u003cp\u003eWhile prior studies have examined the prevalence and individual predictors of suicidal ideation (SI), limited research has explored the mechanism linking academic stress (AS) to SI through major depressive symptoms (MDS), particularly in under-researched regions like Manipur, Northeast India. This study examines the associations between AS, MDS, and SI, and whether MDS mediates the relationship between AS and SI, adjusting for a range of socio-demographic factors.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted among 861 school-going adolescents (Grades 9\u0026ndash;12) from six randomly selected schools in Imphal, Manipur, between August and October 2024. Data were collected using self-administered questionnaires, assessing AS (Educational Stress Scale for Adolescents [ESSA]), MDS (Patient Health Questionnaire-8 [PHQ-8]), and SI (Item 9 of the PHQ-A) and socio-demographics. Analyses included descriptive statistics, chi-square tests, logistic regression, and mediation analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eHigh AS (88.3%), positive for MDS (41.7%), and SI (43.9%) were prevalent. SI prevalence was significantly higher among students with high AS (47.5%) and MDS (69.4%). Logistic regression identified both AS (OR\u0026thinsp;=\u0026thinsp;2.71) and MDS (OR\u0026thinsp;=\u0026thinsp;5.49) as significant predictors of SI. Mediation analysis confirmed that AS predicted MDS (OR\u0026thinsp;=\u0026thinsp;12.02), which in turn predicted SI, with a significant partial mediation effect. Causal mediation analysis revealed that 51% of AS\u0026rsquo;s total effect on SI was mediated through MDS (ACME\u0026thinsp;=\u0026thinsp;0.125, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eAS predicts SI directly and via MDS, indicating partial mediation. Findings advocate the need for early, school-based interventions targeting both AS and MDS, especially in high-risk regions like Manipur, Northeast India.\u003c/p\u003e","manuscriptTitle":"The Mediating Role of Major Depressive Symptoms on Academic Stress and Suicidal Ideation among School-going Adolescents in Manipur, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 08:36:10","doi":"10.21203/rs.3.rs-7004743/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-22T13:24:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T11:57:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257923813195505457660384085675615331059","date":"2025-08-12T18:44:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-04T18:29:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118611663972628315074876962758252244286","date":"2025-07-28T12:25:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-07T10:06:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-04T09:41:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-04T01:04:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-04T01:04:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-06-29T20:24:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f6df2774-dc4b-4fe4-b68f-e714e234ef57","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T15:59:21+00:00","versionOfRecord":{"articleIdentity":"rs-7004743","link":"https://doi.org/10.1186/s12889-025-24901-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-04 15:57:06","publishedOnDateReadable":"November 4th, 2025"},"versionCreatedAt":"2025-07-14 08:36:10","video":"","vorDoi":"10.1186/s12889-025-24901-8","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24901-8","workflowStages":[]},"version":"v1","identity":"rs-7004743","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7004743","identity":"rs-7004743","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}