Mental health of South Korean adolescents in the COVID-19 Era: Web-based survey focused on suicide-related factors

As a result of its high infectivity, the coronavirus disease 2019 (COVID-19) has spread rapidly worldwide and has caused many deaths. However, its impact is not limited to physical morbidity and mortality, as it has triggered a global financial crisis, substantial sociocultural changes, and modified individuals’ daily lives. Meanwhile, the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic affected individuals across 30 different countries. A study that evaluated the mental health of a sample of SARS survivors from Hong Kong reported that 30 months after the epidemic had ended, 47.8% were still experiencing posttraumatic stress disorder and 25.6% were showing persistent mental health problems [1].

As a result of its high infectivity, the coronavirus disease 2019 (COVID-19) has spread rapidly worldwide and has caused many deaths. However, its impact is not limited to physical morbidity and mortality, as it has triggered a global financial crisis, substantial sociocultural changes, and modified individuals’ daily lives. Meanwhile, the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic affected individuals across 30 different countries. A study that evaluated the mental health of a sample of SARS survivors from Hong Kong reported that 30 months after the epidemic had ended, 47.8% were still experiencing posttraumatic stress disorder and 25.6% were showing persistent mental health problems [1].

In May 2015, an outbreak of the Middle East Respiratory Syndrome reached South Korea, resulting in the closure of some schools and hospitals, and individuals with suspected symptoms were required to self-isolate for two weeks. A study of individuals who completed their isolation by mid-June 2015 found that by September to November 2015, 50% were still feeling anxiety and 50% were feeling anger; further, at approximately 4–6 months after their isolation, 20% continued to feel anxiety and 30% felt anger [2]. There is also evidence from various countries—China included—of the mental health problems evoked by COVID-19 on the general population, showing relatively high rates in the studied nations for the following problems: anxiety (6.33–50.9%), depression (14.6–48.3%), post-traumatic stress disorder (7–53.8%), psychological stress (34.43–38%), and stress (8.1–81.9%) [3].

In 2019, a community health survey report conducted in South Korea showed that 3.79% of the general population were in the depression risk group and 4.7% of the adults reported experiencing suicidal thoughts. Then, in September 2020, an online survey was conducted and showed that the percentage of people in the depression risk group had risen to 22.1% and the suicide thoughts rate was 13.8%. Moreover, results from the 2021 COVID-19 National Mental Health Survey, conducted by the Korean Trauma Stress Association and the Ministry of Health and Welfare, showed that the percentage of people in the depression risk group was 22.8% in March (decreasing to 18.9% in December), and that of people who reported experiencing suicidal thoughts was 16.3% in March (decreasing to 13.6% in December) [4]. The figures above show that depression rates and suicide thoughts decreased over time in South Korea [5]. There was another South Korean survey-based study that conducted, from April to August 2020, an investigation on the impact of the prolonged COVID-19 pandemic on the mental health of 500 adults; the percentages of people in the depression risk group in April and August were 18.4% and 23.2%, respectively, and those of people in the anxiety risk group were 11.8% and 16.0%, respectively [6]. Other studies remark that the psychological responses that emerge at the population level during an infectious disease outbreak can both accelerate the spread of the disease and trigger emotional distresses and social impairments that persist even after disease eradication [7, 8].

The first report of a COVID-19 patient in South Korea took place on 20 January 2020. Afterwards, in a single month, there was around 8,000 cumulative confirmed cases in Daegu and Gyeongsangbuk-do, making this the second largest number of cumulative confirmed cases, losing only to China. On 12 March 2020 (Korea Standard Time), the World Health Organization officially declared the COVID-19 pandemic. In August 15, after the Liberation Day rally, there was even a second wave of COVID-19 in two locations in Seoul, namely Gwanghwamun and the Sarang First Church in Seongbuk-gu. The government also imposed social distancing policies during the beginning of the pandemic, which led to the postponing of the opening of elementary, middle, and high schools three times. Accordingly, remote classes began on 9 April 2020, and in the second semester of 2020, real-time video classes became the common trend at all stages of education.

Adolescence is a key period for the development of one’s character; however, the continued threat of the COVID-19 pandemic means that many adolescents have been forced to spend some of their formative years in relative isolation. The consequent psychological anxiety and depressive symptoms that some of these adolescents may have experienced have had a tremendous negative impact on their mental health [9]. Moreover, researchers show that the association of normal stress with daily and major life events can exacerbate the aforementioned psychological distresses and increase the risk of depression and anxiety later in life [10].

In 2020, South Korea had the highest age-standardized suicide rate (23.5) among Organisation for Economic Co-operation and Development countries [11], with suicide being the leading cause of death among South Korean individuals aged 10–39 years. While the total number of suicide deaths in South Korea in 2021 showed a slight drop compared with the figures for the preceding year, the suicide rate of individuals aged 10–29 years showed a marked increase [12]. In particular, studies show that sorrow, hopelessness, and depression, all of which can be consequences of the effects of the pandemic, can increase the risk of suicidal ideation [13, 14]. Researchers also demonstrate that measures such as social distancing or lockdowns for preventing COVID-19 infection and mortality are crucial for facilitating the country’s economic and social recovery [15]. Still, it remains that such measures should be accompanied by means of mitigating their effects on mental health.

Accordingly, examinations of adolescent mental health and related problems amid the COVID-19 pandemic could inform the development of specialized education programs that promote positive mental health among this age group. Therefore, this study examined adolescent mental health using data on the health behavior status of South Korean sixth to eighth graders in middle school nationwide during the prolonged COVID-19 pandemic.

Since the outbreak of COVID-19 in Hubei, China, in December 2019, restrictions have been imposed on people’s daily lives to address the threat of the virus; however, these restrictions have had prolonged negative consequences. The severing of social relationships owing to measures such as social distancing has resulted in mental health problems in the general population, and fear of quarantine has led to depression, anxiety, stress, and despair, thereby impairing people’s quality of life. In particular, 59.8% of adolescents in South Korea have reported dominant feelings of “anxiety and worry” as a result of the COVID-19 pandemic [37]. Thus, this study analyzed the factors associated with mental health issues and suicide among adolescents by categorizing a representative sample of South Korean adolescents into four groups: a healthy group, suicide-ideation group, suicide-planning group, and suicide-attempt group. We sought to specifically identify the predictors of related mental health issues. The following results were obtained.

First, among 57,925 South Korean adolescents, 6.9% showed suicidal ideation, 2.2% reported planning suicide, and 1.9% reported attempting suicide over the 12 months preceding the data collection. These rates are lower than those reported in a 2019 study conducted in the United States among children and adolescents, wherein 18.8% reported seriously considering attempting suicide, 15.7% reported planning suicide, and 8.9% reported attempting suicide [41]. The above data show that adolescents in South Korea and the US are more likely to engage in suicidal ideation than to actually plan or attempt suicide [42]. However, in Ghana’s Global School-based Student Health Survey conducted in 2012 for high school students, the prevalence of suicidal thoughts, suicide plans, and suicide attempts was 18.2%, 22.5%, and 22.2%, respectively. Therefore, further research is needed on these differences in suicide-related variables between countries [43]. Moreover, although there is a large discrepancy between suicidal ideation and suicidal behavior among adolescents, this contrasts the situation of middle-aged and older adults [44]. Still, as adolescents have relatively less life experience and tolerance of various forms of shocks and stressors than do their older counterparts, they can be more impulsive regarding suicide. This indicates the need for national policies in South Korea that exclusively target suicide prevention among adolescents.

Second, all demographic characteristics examined in this study, except for fathers’ highest education level, significantly predicted adolescents’ mental health status. In the healthy group, male high schoolers with higher academic achievement were mentally healthier. In the suicide-ideation and suicide-attempt groups, female high schoolers with poor grades showed a higher risk of mental health problems. When compared to the healthy group, the risk of mental health problems was higher among students who were not living with family members, those who had a lower socioeconomic status, and those who reported planning or attempting suicide. The risk of stress, sadness and despair, loneliness, or GAD was higher among those who had experienced greater financial difficulty as a result of the COVID-19 pandemic. The risk was also higher among those with inadequate sleep, smokers, alcohol users, those with experience using drugs, and those with smartphone overdependence as compared to their counterparts. The level of financial assistance received had little effect.

The risk to attempt suicide was higher among female high schoolers with “poor” academic achievement, those living with non-family members, and those with lower economic status as compared to their counterparts. The risk of suicidal ideation, suicide planning, and suicide attempt was higher among those with inadequate sleep, smokers, alcohol users, those with experience using drugs, and those with smartphone overdependence. The findings for sex in this study are similar to those of previous South Korea-based studies, in which the risks of suicidal ideation, suicide planning, and suicide attempt were higher among female than male students [45‐47]. A possible reason for this is that male students tend to interpret an event cognitively, while female students are more heavily influenced by and sensitive to the emotional aspects of the event [47, 48]. Between 2010 and 2017, the mean suicide rate among adolescents aged 10–19 years in South Korea was 5.45% for boys and 4.30% for girls, differing from the US rates of 7.57% for boys and 2.57% for girls [49]. Both the South Korean and US data show differences between sexes, which indicates that a sex-specific approach should be taken to address this issue.

As aforementioned, the results showed that sleep, smoking, alcohol, drugs, and smartphone overdependence were associated with the risk of suicide. This shows the necessity of helping students recover psychologically and improve their quality of life; this can be done by providing various forms of support for their mental and psychological conditions within the educational system, as past studies also show that drinking, smoking, drug use, or excessive experience of smartphones in adolescence harms physical health [22, 23, 50]. According to the SEYLE Cluster Randomized Controlled Trial (German Clinical Trials Register DRKS00000214), which encompassed 11,110 high school students in 10 EU countries, specific school-based suicide prevention interventions were effective in mitigating the dangerous effects of self-harm behavior; these interventions could also be further developed by increasing parental participation [51]. Parental support and encouragement may be one of the key factors for adolescents to be able to avoid suicidal thoughts. This suggests that the role of parents in recognizing adolescents as part of the family is essential for adolescent suicide prevention, as parental affirmation may help adolescents perceive themselves as valuable. Thus, to promote adolescent suicide prevention in South Korea, education systems and parents should facilitate or provide various forms of psychological support to adolescents, as these efforts may help strengthen adolescent mental health and, in turn, quality of life.

Furthermore, humanity has now already experienced how much our daily lives can change very quickly upon the onset of a pandemic, such as that provoked by COVID-19. Thus, we should conduct in-depth discussions on how our daily lives would be like in the upcoming post-COVID-19 period. To systematically respond to these forthcoming periods of human history, we could develop and apply digital platform education programs aimed at improving adolescent health behaviors and mental health, especially among those who had their lives impacted by the COVID-19 pandemic. Once more, education systems can play a significant role on the topic, as they can provide adolescents with various forms of psychological support so as to strengthen their mental health and quality of life.

Third, we comparatively analyzed mental health and suicide-related factors. The results showed that negative emotions such as depression among adolescents increase the odds of their progressing from suicidal ideation to attempting suicide. This supports previous findings that adolescents with emotional problems exhibit high levels of depressive symptoms, stress, and impulse to drop out of school [52], and that loneliness is a powerful predictor of suicidal ideation [53, 54]. Contrastingly, Naragon-Gainey and Watson [55] reported that while depression is a significant factor in suicidal ideation, GAD is not. Another study shows that emotional intelligence associates with health indices, and that decreasing emotional intelligence relates to increasing suicidal behavior [56]. In an analysis of the components and behavioral risk reduction of adolescent mental health programs for those aged 10–19 across 18 studies, the interventions were shown to universally improve adolescent mental health and reduce risk behaviors [57]. Thus, programs that cultivate one’s ability to control and positively manage emotions should be provided for adolescents who are psychologically unstable and who are repeatedly exposed to negative emotions; this could help to promote psychological stability and functionality.

Fourth, we identified factors that predict adolescents’ mental health status. Specifically, sex, academic achievement, economic status, impact of COVID-19 on economic status, sleep, alcohol use, drug use, smartphone overdependence, and suicide-related factors were identified as significant predictors. Many studies have similarly reported that sex, academic achievement, economic status, health behaviors, and emotional characteristics influence adolescents’ mental health and suicidal ideation [58, 59]. Further, studies exploring the influence that COVID-19-induced changes in subjective economic status have on adolescents’ stress have found that deterioration in economic status has a negative impact on adolescents’ mental health [60‐62].

Past studies on suicide have generally examined predictors of suicidal ideation. Contrastingly, this study classified adolescents into four groups, namely the healthy, suicide-ideation, suicide-planning, and suicide-attempt groups. Thus, the significance of this study lies in considering suicide not as a simple, isolated event, but rather as a complex and dynamic process that forms a continuum from suicidal ideation through planning suicide to attempting suicide. Thus, in examining the demographic characteristics and the transition to suicidal attempt in individuals in the healthy group, we shed light on the specific directions that can be taken for interventions targeting each stage of mental health crisis among adolescents, from suicidal ideation to suicidal planning and suicide attempt. Further, while past studies have generally focused on depression when examining factors associated with suicide in adolescents, we confirmed that sadness and despair and GAD elevate the risk of suicidal ideation, suicide planning, and attempting suicide. These findings collectively showcase the need for programs that, through accurate mental health evaluations, focus on these factors and enable the early screening and implementation of interventions for adolescents at risk of suicide. Another strength of this study is that it provides an opportunity to identify new means of maintaining adolescents’ mental health amid the prolonged COVID-19 pandemic.

Suicide is an outcome of complicated, dynamic, and unique interactions among numerous contributors [60]. Thus, educational programs and campaigns that raise awareness of behaviors that increase the risk of suicide (e.g., smoking and drug and alcohol use) should be frequently conducted to improve adolescents’ mental health status. Additionally, individualized mental health programs should be developed to help adolescents manage their mental health, as this would contribute to addressing the emotional aspects and other factors associated with suicide (e.g., stress, depression, loneliness). Childhood and adolescence are critical periods for physical and emotional growth and development, and COVID-19-induced changes in daily life can have a tremendous impact on young people’s future lives. Hence, as the COVID-19 pandemic continues, it is important to pay attention, both in the social context and in research, to restrictions in daily life that can affect adolescents’ mental health, and to mitigate these effects where possible.