Relationship Between Social Isolation, Seclusion, and Suicidal Ideation Among Young Adults: An Analysis of Data From the 2022 Survey on the Lives of Young People in Korea

Article information

J Prev Med Public Health. 2025;58(5):496-504

Publication date (electronic) : 2025 May 8

doi : https://doi.org/10.3961/jpmph.24.792

Jiwon Shin ¹

, Hyun Yang ¹

, Mu Won Lee ¹

, Hae Yean Park ²

, Suyeong Bae ²

¹Department of Occupational Therapy, Graduate School, Yonsei University, Wonju, Korea

²Department of Occupational Therapy, College of Software and Digital Healthcare Convergence, Yonsei University, Wonju, Korea

Corresponding author: Suyeong Bae, Department of Occupational Therapy, College of Software and Digital Healthcare Convergence, Yonsei University, 1 Yeonsedae-gil, Wonju 26493, Korea, E-mail: sbae1@yonsei.ac.kr

Received 2024 December 30; Revised 2025 April 8; Accepted 2025 April 11.

Abstract

Objectives

This study aimed to investigate the current status of social isolation and seclusion among young adults in Korea and to analyze their association with suicide risk.

Methods

We utilized data from 14 966 young adults aged 19–34 years from the 2022 Survey on the Lives of Young People. Social isolation and seclusion were defined as independent variables, and suicidal ideation within the past year was set as the dependent variable. Propensity score matching (PSM) was employed to reduce the risk of selection bias, and logistic regression analysis was conducted to examine the associations between social isolation, seclusion, and suicidal ideation.

Results

Of the participants, 266 individuals (1.8%) were socially isolated, and 67 individuals (0.5%) were secluded. Associations were observed between social isolation and suicidal ideation (population-weighted adjusted model: odds ratio [OR], 2.43, p=0.003; population-weighted PSM model: OR, 2.03, p=0.037), as well as between seclusion and suicidal ideation (population-weighted adjusted model: OR, 4.15, p=0.004; population-weighted PSM model: OR, 3.87, p=0.010) across all models.

Conclusions

Being socially isolated or secluded is associated with an increased risk of suicidal ideation among young adults aged 19–34 years. Preventive policies and tailored support systems are urgently needed to address these risks. This study contributes to the development of specific policies for mitigating social isolation and supporting the reintegration of young adults aged 19–34 years into society.

Keywords: Propensity score; Republic of Korea; Social isolation; Suicidal ideation; Young adult

INTRODUCTION

The suicide rate among young adults in Korea is increasing. Suicide is currently the leading cause of death among individuals in their 20s and 30s, with the suicide rate among those in their 30s being the highest among member countries of the Organization for Economic Cooperation and Development (OECD) [1]. Although the overall suicide mortality rate in Korea has been declining since 2011—largely driven by a substantial decrease in suicide rates among older adults—data from reputable institutions, such as the OECD, indicate that suicide rates among young adults remain disproportionately high. This underscores the urgent need for increased attention to suicide among young adults in Korea [2]. Moreover, recent discussions have linked social isolation during the coronavirus disease 2019 (COVID-19) pandemic to increased suicidal ideation [3].

Social isolation is defined as a state characterized by limited social interaction and insufficient qualitatively meaningful relationships [4,5]. In Korea, prior policies and research on social isolation have predominantly focused on older adults. However, there has recently been growing attention toward socially isolated and secluded young adults, with the first policies targeting this demographic having been announced. In the 2022 Survey on the Lives of Young People, socially isolated and secluded individuals were defined as those lacking meaningful social relationships and support systems to rely upon during times of need [6]. In this survey, social isolation was measured based on respondents’ perceived availability of social support, while seclusion was assessed by the frequency of leaving one’s residence [6]. Furthermore, although social isolation among young adults may share similarities with isolation among older adults in terms of requiring external interventions, previous studies have emphasized that isolation and seclusion among young adults constitute unique and emerging social risks [7]. According to a 2022 survey conducted by the Office for Government Policy Coordination, approximately 540 000 young adults in Korea were estimated to be socially isolated or secluded [6].

Social isolation and seclusion among young adults are significant risk factors for various adverse life outcomes. Young adulthood is a developmental period characterized by increasing independence from parents, establishing the foundations for life, and pursuing goals such as employment and marital relationships [8]. Failure to achieve these milestones can lead to negative emotions, including anxiety, fear, and helplessness, and may result in reduced interactions with external environments [9]. Furthermore, previous studies have demonstrated that social isolation and seclusion negatively affect mental health, particularly highlighting young adults’ vulnerability to loneliness due to inadequate social relationships, thus necessitating external support [10]. The longer the period of isolation and seclusion, the greater the psychological and emotional vulnerability, thereby exacerbating risks to mental health [11,12].

Among the risks associated with social isolation and seclusion, their connection with suicide has repeatedly been highlighted. Suicide, defined as self-inflicted harm leading to death, has profound implications not only for the individual but also for their family, community, and society at large, making it a critical public health concern [13]. Although research on suicide and loneliness has traditionally focused on older adults, only a few studies have specifically addressed young adults in Korea over the past decade. For instance, Lee et al. [14] investigated the causes of suicide among young adults in relation to social isolation, emphasizing how competitive societal structures in Korea foster feelings of comparison and relative deprivation, indirectly and directly increasing suicide risk. Similarly, Noh et al. [12] conducted an in-depth analysis of the causes of social seclusion based on the experiences of young adults in Korea. However, research specifically addressing the association between suicide and socially isolated or secluded young adults remains scarce. Moreover, nationwide studies investigating the prevalence and current status of social isolation and seclusion among young adults in Korea are notably lacking.

According to a nationwide survey involving approximately 14 000 socially isolated and secluded young adults, more than 80% expressed a desire to overcome their current situation, and nearly 45% had attempted societal reintegration but subsequently relapsed into isolation or seclusion [6]. Prolonged social isolation and seclusion during young adulthood can persist into middle and older adulthood, further compounding the risk of suicide across different life stages [7]. Moreover, the economic costs associated with social isolation and seclusion are estimated at approximately 1.5 billion Korean won (approximately US$1 million) per individual [15]. Although existing literature strongly advocates for research on socially isolated or secluded young adults, there remains a scarcity of effective analyses and evidence-based strategies to address their needs. Thus, raising awareness regarding the prevalence of social isolation and seclusion in Korea and exploring active support measures are imperative. This study investigated the current state of socially isolated and secluded young adults in Korea and analyzed the relationships between social isolation, seclusion, and suicidal ideation.

METHODS

Study Data and Participants

We extracted data from 14 966 young adults participating in the 2022 Survey on the Lives of Young People, conducted by the Office for Government Policy Coordination, the Prime Minister’s Secretariat, and the Korea Institute for Health and Social Affairs. Participants comprised young adults aged 19–34 years from 17 cities and provinces nationwide in 2022. The survey included personal interview items covering general demographics, living conditions, health status, education, employment, relationships, and employment-related characteristics. We planned to exclude individuals with missing data; however, no participant had missing values. Therefore, our final sample included all 14 966 young adults.

Variables

The independent variables were social isolation and seclusion. Social isolation was assessed using responses to the question: “Is there a particular group you would prefer to seek help from when facing challenges such as [illness of yourself or a family member, feelings of depression or stress, or experiencing unfair treatment in daily life]?” This was measured using a 5-point Likert scale: family (relatives), acquaintances (friends, neighbors, coworkers, etc.), public institutions (community centers, government agencies, etc.), private organizations (religious groups, social welfare organizations, etc.), and no person or institution to seek help from. Participants who answered “no person or institution to seek help from” for at least two of the three presented scenarios were assigned to the socially isolated group; the remaining participants were assigned to the socially non-isolated group. Seclusion was assessed based on participants’ frequency of leaving their residence, measured using an eight-point Likert scale: “I go out every weekday for work or school,” “I go out 3–4 days a week for work or school,” “I often go out for leisure activities,” “I occasionally go out to meet people,” “I usually stay at home, but I go out only for my hobbies,” “I usually stay at home, but I go out to nearby places like convenience stores,” “I leave my room, but I do not go outside the house,” and “I rarely leave my room.” Participants who selected “I usually stay at home, but I go out to nearby places like convenience stores,” “I leave my room, but I do not go outside the house,” or “I rarely leave my room,” had maintained this status for over one year, and did not cite pregnancy/childbirth or disability as reasons, were classified into the secluded group. All other participants were assigned to the non-secluded group.

The dependent variable was suicidal ideation within the past year, measured using the question, “Have you seriously considered suicide in the past year?” Participants who responded “yes” were coded as 1, and those who responded “no” were coded as 0. Covariates included demographic characteristics (sex, age, region, and educational attainment), lifestyle factors (smoking, drinking, and exercise), physical health indicators (experience with sleeping pills, experience with tranquilizers, and self-rated health), and mental health factors (experience with burnout, depression, and unmet mental health needs).

Statistical Analysis

The demographic and clinical characteristics of participants are presented as frequencies and percentages for categorical variables, based on both raw and population-weighted samples. To analyze the association between suicidal ideation and social isolation or seclusion, logistic regression analyses were conducted separately for each independent variable. Additionally, to mitigate potential selection bias arising from secondary data analysis, propensity score matching (PSM) was employed. Therefore, the analytical models consisted of two separate sets: (1) the isolation model included the population-weighted unadjusted model, population-weighted adjusted model, and population-weighted greedy 1:3 matching logistic regression model; and (2) the seclusion model included the population-weighted unadjusted model, population-weighted adjusted model, and population-weighted greedy 1:3 matching logistic regression model. PSM is a statistical method designed to reduce selection bias by controlling confounding variables. This approach involves calculating propensity scores, after which individuals with similar or identical propensity scores are matched because the distributions of all covariates used to generate the propensity score are assumed to be similar or identical between matched pairs [16]. Greedy matching is a specific PSM technique wherein each treated individual is sequentially matched with the best available untreated counterpart [17]. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Ethics Statement

This study received approval from the Institutional Review Board of Yonsei University Mirae Campus (No. 1041849-202411-SB-223-01).

RESULTS

Demographic and Clinical Characteristics

Table 1 presents the raw and population-estimated demographic and clinical characteristics of the participants according to whether they were socially isolated. Of the total sample, 266 individuals (1.8%) were categorized as socially isolated, comprising 130 males (48.9%) and 136 females (51.1%). Participants in the socially isolated group exhibited a higher frequency of negative experiences—such as burnout, unmet medical needs, use of sleeping pills or tranquilizers, and depressive symptoms—compared to individuals who were not isolated.

Table 1

Demographic characteristics of the participants according to whether they were isolated

Table 2 displays the raw and population-estimated demographic and clinical characteristics of participants according to their seclusion status. Within the sample, 67 individuals (0.4%) were classified into the secluded group, comprising 35 males (52.2%) and 32 females (47.8%). Similar to the results in Table 1, participants in the secluded group had higher frequencies of negative experiences—including burnout, unmet medical needs, use of sleeping pills or tranquilizers, and depressive symptoms—compared to those in the non-secluded group.

Table 2

Demographic characteristics of the participants according to whether they were secluded

Associations Between Suicidal Ideation and Demographic and Clinical Characteristics

Supplemental Materials 1 and 2 present the associations between suicidal ideation and participants’ demographic and clinical characteristics in models 2 and 5. Burnout (odds ratio [OR], 3.46, p<0.001; OR, 3.52, p<0.001), unmet medical needs in mental health (OR, 7.46, p<0.001; OR, 7.44, p<0.001), use of tranquilizers (OR, 4.61, p<0.001; OR, 4.69, p<0.001), very poor self-rated health (OR, 5.90, p=0.009; OR, 6.27, p=0.006), and depressive symptoms (OR, 1.88, p=0.042; OR, 1.91, p=0.037) were positively associated with suicidal ideation in both models. In contrast, demographic and lifestyle variables such as age, sex, region, marital status, smoking, alcohol consumption, and regular physical activity were not associated with suicidal ideation in either model.

Associations Between Social Isolation, Seclusion, and Suicidal Ideation

Table 3 presents the ORs for the associations between social isolation and suicidal ideation. Across all models, social isolation was positively associated with suicidal ideation (population-weighted unadjusted model: OR, 4.76; population-weighted adjusted model: OR, 2.43; population-weighted PSM: OR, 2.03; all models p<0.05). Table 4 presents the ORs for the associations between seclusion and suicidal ideation. Similar to social isolation, seclusion was positively associated with suicidal ideation across all models (population-weighted unadjusted model: OR, 5.60; population-weighted adjusted model: OR, 4.15; population-weighted PSM model: OR, 3.87; all models p<0.05). These findings suggest that socially isolated or secluded individuals are significantly more likely to experience suicidal ideation.

Table 3

Association between social isolation and suicidal ideation in various models

Table 4

Association between seclusion and suicidal ideation in various models

DISCUSSION

This study investigated the current state of socially isolated and secluded young adults in Korea and the association between social isolation, seclusion, and suicidal ideation using data from the 2022 Survey on the Lives of Young People. Our findings indicate that young adults who are socially isolated or secluded should be closely monitored and supported to prevent suicide.

Participants were categorized into socially isolated and secluded groups to analyze their associations with suicidal ideation. The results showed that suicidal ideation rates were significantly higher among socially isolated and secluded young adults compared to their non-isolated and non-secluded counterparts. Notably, these elevated rates are comparable to the national lifetime suicidal ideation rate of 10.7% reported by Statistics Korea [18], which underscores the severity of the mental health risk for these vulnerable populations. The findings of this study can be summarized into three key points: (1) the prevalence of negative factors, such as burnout and depressive symptoms, was higher among socially isolated and secluded young adults; (2) these negative factors were associated with higher rates of suicidal ideation among young adults; and (3) social isolation and seclusion themselves were directly associated with suicidal ideation.

Socially isolated and secluded young adults experienced higher rates of burnout and perceived their health more negatively compared to their non-isolated and non-secluded counterparts. These findings align with previous studies indicating that lower levels of social support increase the risk of burnout and negatively impact self-rated health [19]. Furthermore, socially isolated and secluded young adults reported higher rates of depressive symptoms, unmet medical needs, and the use of sleeping pills or tranquilizers. Social isolation has well-documented negative physical and mental health consequences [5,20]. The higher prevalence of unmet medical needs and greater use of sleeping pills or tranquilizers among socially isolated and secluded young adults suggest not only increased medical service demands but also challenges in obtaining adequate and sustained care. The relationship between social isolation and unmet medical needs may involve complex factors, such as the absence of support networks and financial difficulties [21], highlighting the need for additional research to better understand these interactions.

Burnout, depression, unmet medical needs, negative self-rated health, and the use of sleeping pills or tranquilizers were identified as significant variables associated with suicidal ideation among young adults. Among these factors, unmet mental health needs showed the highest OR, indicating a particularly strong association with suicidal ideation. Our findings suggest that mental health factors are closely linked to suicidal ideation. Prior studies have similarly reported mental health as a vulnerability characteristic associated with social isolation and seclusion among young adults [22,23]. These results imply that the strong relationships between mental health factors and suicide found in this study apply particularly to socially isolated and secluded young adults. However, our study did not deeply examine the intricate relationships among these variables. Future research should comprehensively explore the various factors related to socially isolated and secluded young adults and their interconnections.

All analytical models in this study, including population-weighted unadjusted, population-weighted adjusted, and population-weighted PSM models, consistently showed significantly higher suicidal ideation rates among socially isolated and secluded young adults. These findings align with prior studies indicating that suicide attempts are influenced by factors related to social participation [17], emphasizing the importance of addressing social isolation and seclusion in suicide prevention strategies. Additionally, to address potential selection bias, we employed PSM alongside logistic regression analysis, both of which have been widely utilized in previous studies. This methodological approach enhanced the robustness of our findings and mitigated inherent limitations common to secondary data analyses. By employing PSM, this study demonstrates an effective method for future researchers aiming to reduce selection bias and improve the validity of their results.

Based on these analyses, our findings suggest two key implications. First, preventive measures targeting social isolation and seclusion are essential. Our results showed that burnout was significantly associated with suicidal ideation. Previous studies suggest burnout can result from prolonged struggles related to employment or interpersonal relationships [24,25], both identified as primary factors contributing to social isolation and ultimately suicide among young adults [5,26–28]. Interviews with socially isolated and secluded young adults revealed expressions such as “I never slept well during my job search” and “I do not know how to form relationships” [29]. Furthermore, the 2022 Survey on the Lives of Young People found that more than 80% of socially isolated and secluded young adults wished to escape their current state; however, 45% relapsed into isolation after attempting societal reintegration [6]. Many young adults face compounded difficulties in employment and achieving independence due to prolonged isolation, often leading to further seclusion. Beyond individual-level struggles, the absence of sufficient social safety nets exacerbates young adults’ susceptibility to isolation in Korea. Failure to achieve developmental milestones, such as employment and marriage, can lead abruptly to social isolation and seclusion, with prolonged isolation further hindering the possibility of reintegration [30]. Therefore, comprehensive preventive interventions and tailored support systems are critically needed to protect young adults from becoming socially isolated and secluded.

Second, identifying vulnerable young adults and establishing systematic support frameworks is imperative. Policies addressing socially isolated and secluded young adults have only recently begun taking shape, with significant initiatives launched by the national government following the enactment of the Young Adults Act in 2020. Dedicated support plans, however, were not announced until 2023, accompanied by the initiation of pilot programs [31]. Nonetheless, these efforts have remained limited in scope. Implementing proactive programs designed to identify and support socially isolated and secluded young adults through collaboration with local government agencies is crucial. In our study, unmet mental health needs emerged as the most significant factor associated with suicidal ideation. Collaboration with community-based institutions, such as mental health centers and suicide prevention centers, could facilitate the identification of socially isolated and secluded clients and provide multifaceted, tailored assistance to at-risk young adults. Social isolation among young adults often involves complex, interrelated factors, and isolated individuals may lack awareness of their circumstances [29]. Moreover, inadequate information and resources may hinder socially disconnected individuals from accessing appropriate support services. The findings of this study could assist in identifying and supporting socially isolated and secluded young adults experiencing difficulties within their communities.

This study has several limitations. First, as a cross-sectional study, it is limited in establishing causal relationships between social isolation, seclusion, and suicidal ideation. Nevertheless, the 2022 Survey on the Lives of Young People represents the first nationwide investigation of socially isolated and secluded young adults, and subsequent longitudinal studies are expected to clarify temporal and causal associations. Second, the criteria used to identify socially isolated young adults relied on whether they had access to social support when facing challenges. Although this approach objectively measures social isolation, it does not fully capture the subjective experience of isolation. Future research should include these subjective dimensions to achieve a more comprehensive understanding of social isolation among young adults.

This study highlights that social isolation and seclusion contribute to the high prevalence of suicidal ideation among young adults. These individuals can thus be identified as a population at significant risk. Young adults are notably vulnerable to loneliness, social isolation, and seclusion, which can be exacerbated by challenges in employment and interpersonal relationships. Thus, preventive and supportive measures are essential to address these vulnerabilities. Furthermore, tailored policies are urgently needed to support socially isolated and secluded young adults in achieving independence and successful reintegration into society.

Supplemental Materials

Supplemental materials are available at https://doi.org/10.3961/jpmph.24.792.

Supplementary Material 1.

Association between participant characteristics and suicidal ideation in Model 2 (N = 10,077,124)

jpmph-24-792-Supplementary-Material-1.docx

Supplementary Material 2.

Association between participant characteristics and suicidal ideation in Model 5 (N = 10,077,124)

jpmph-24-792-Supplementary-Material-2.docx

Notes

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

None.

Author Contributions

Conceptualization: Bae S, Park HY. Data curation: Bae S. Formal analysis: Bae S. Funding acquisition: None. Methodology: Bae S. Project administration: Bae S, Park HY, Shin J. Visualization: Bae S, Park HY, Shin J. Writing – original draft: Bae S, Shin J, Yang H, Lee MW. Writing – review & editing: Bae S, Park HY.

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Characteristics		Raw samples (n=14 966)		Population-estimated samples (n=10 077 124)
		Not isolated (n=14 700, 98.2%)	Isolated (n=266, 1.8%)	Not isolated (n=9 903 178, 98.3%)	Isolated (n=173 946, 1.7%)
		Age (y)	19–24	7089 (98.5)	106 (1.5)	3 500 867 (98.4)	55 860 (1.6)
25–29	4470 (98.3)		79 (1.7)	3 384 750 (98.4)	54 742 (1.6)
30–34	3141 (97.5)		81 (2.5)	3 017 561 (97.9)	63 344 (2.1)
Sex	Male	7041 (98.2)	130 (1.8)	5 198 025 (98.2)	92 859 (1.8)
Sex	Female	7659 (98.3)	136 (1.7)	4 705 153 (98.3)	81 087 (1.7)
Region	Metropolitan area	4851 (98.2)	87 (1.8)	5 244 616 (98.2)	97 861 (1.8)
Region	Non-metropolitan area	9849 (98.2)	179 (1.8)	4 658 562 (98.4)	76 085 (1.6)
Marital status	Married	1534 (97.7)	36 (2.3)	1 731 530 (98.1)	32 880 (1.9)
	Not married	13 041 (98.3)	227 (1.7)	8 098 992 (98.3)	139 920 (1.7)
	Others (divorced, separated, widowed)	125 (97.7)	3 (2.3)	72 655 (98.5)	1147 (1.5)
Educational attainment	Below high school	2029 (97.4)	55 (2.6)	1 442 272 (97.8)	31 897 (2.2)
	Enrolled in college/on leave	4673 (98.7)	62 (1.3)	2 378 640 (98.5)	35 353 (1.5)
	Above college graduate	7999 (98.2)	149 (1.8)	6 082 266 (98.3)	106 697 (1.7)
Smoking	Non-smoker	5977 (98.7)	78 (1.3)	3 942 260 (98.9)	44 740 (1.1)
	Former smoker	1019 (98.3)	18 (1.7)	799 682 (98.7)	10 412 (1.3)
	Current smoker	7704 (97.8)	170 (2.2)	5 161 236 (97.8)	118 794 (2.2)
Alcohol consumption	Non-drinker	3007 (97.8)	67 (2.2)	1 942 998 (97.8)	44 823 (2.2)
	≤1 times/mo	4532 (98.2)	81 (1.8)	3 000 322 (98.2)	54 029 (1.8)
	Approximately 2–4 times/mo	4986 (98.6)	72 (1.4)	3 395 365 (98.6)	49 863 (1.4)
	Approximately 2–3 times/wk	1805 (98.2)	34 (1.8)	1 307 971 (98.5)	20 070 (1.5)
	≥4 times/wk	370 (96.9)	12 (3.1)	256 522 (98.0)	5162 (2.0)
Regular physical activity (times/wk)	≥5	1719 (98.4)	28 (1.6)	1 095 811 (98.1)	21 338 (1.9)
	3–4	3097 (98.4)	51 (1.6)	2 131 533 (98.3)	36 739 (1.7)
	1–2	4170 (98.3)	74 (1.7)	2 838 273 (98.4)	47 272 (1.6)
	<1	1778 (98.5)	27 (1.5)	1 236 594 (98.6)	17 636 (1.4)
	Never exercise	3936 (97.9)	86 (2.1)	2 600 967 (98.1)	50 962 (1.9)
Burnout experience (yes)		4736 (97.3)	133 (2.7)	3 319 185 (97.1)	98 344 (2.9)
Unmet medical needs experience: mental health (yes)		397 (93.9)	26 (6.1)	272 315 (94.4)	16 089 (5.6)
Experience with using sleeping pills throughout life (yes)		499 (95.1)	26 (4.9)	368 510 (95.9)	15 592 (4.1)
Experience with using tranquilizers throughout life (yes)		536 (95.2)	27 (4.8)	417 075 (95.8)	18 326 (4.2)
Self-rated health	Very good	1700 (98.9)	19 (1.1)	1 059 437 (99.0)	10 285 (1.0)
	Good	6463 (98.7)	88 (1.3)	4 366 849 (98.7)	57 465 (1.3)
	Fair	5571 (98.0)	113 (2.0)	3 796 190 (98.0)	76 526 (2.0)
	Poor	901 (95.9)	39 (4.1)	639 400 (96.3)	24 743 (3.7)
	Very poor	65 (90.3)	7 (9.7)	42 302 (89.6)	4927 (10.4)
Depression (yes)		9361 (97.8)	209 (2.2)	6 409 695 (97.8)	142 248 (2.2)

Characteristics		Raw samples (n=14 966)		Population-estimated samples (n=10 077 124)
		Not secluded (n=14 899, 99.6%)	Secluded (n=67, 0.4%)	Not secluded (n=10 026 474, 99.5%)	Secluded (n =50 650, 0.5%)
		Age (y)	19–24	7172 (99.7)	23 (0.3)	3 543 392 (99.6)	13 335 (0.4)
25–29	4521 (99.4)		28 (0.6)	3 417 202 (99.4)	22 290 (0.6)
30–34	3206 (99.5)		16 (0.5)	3 065 880 (99.5)	15 025 (0.5)
Sex	Male	7136 (99.5)	35 (0.5)	5 260 740 (99.4)	30 144 (0.6)
Sex	Female	7763 (99.6)	32 (0.4)	4 765 734 (99.6)	20 506 (0.4)
Region	Metropolitan area	4910 (99.4)	28 (0.6)	5 311 331 (99.4)	31 146 (0.6)
Region	Nonmetropolitan area	9989 (99.6)	39 (0.4)	4 715 143 (99.6)	19 504 (0.4)
Marital status	Married	1563 (99.6)	7 (0.4)	1 758 162 (99.7)	6248 (0.3)
	Not married	13 208 (99.6)	60 (0.4)	8 194 510 (99.5)	44 402 (0.5)
	Others (divorced, separated, widowed)	128 (100)	0 (0)	73 802 (100)	0 (0)
Educational attainment	Below high school	2063 (99.0)	21 (1.0)	1 458 960 (99.0)	15 208 (1.0)
	Enrolled in college/on leave	4724 (99.8)	10 (0.2)	2 407 377 (99.7)	6616 (0.3)
	Above college graduate	8112 (99.6)	36 (0.4)	6 160 137 (99.5)	28 825 (0.5)
Smoking	Non-smoker	6044 (99.8)	11 (0.2)	3 977 090 (99.8)	9910 (0.2)
	Former smoker	1034 (99.7)	3 (0.3)	806 901 (99.6)	3194 (0.4)
	Current smoker	7821 (99.3)	53 (0.7)	5 242 483 (99.3)	37 547 (0.7)
Alcohol consumption	Non-drinker	3040 (98.9)	34 (1.1)	1 962 885 (98.8)	24 936 (1.2)
	≤1 time a month	4596 (99.6)	17 (0.4)	3 042 550 (99.6)	11 802 (0.4)
	Approximately 2–4 times/mo	5049 (99.8)	9 (0.2)	3 436 659 (99.8)	8569 (0.2)
	Approximately 2–3 times/wk	1833 (99.7)	6 (0.3)	1 324 083 (99.7)	3957 (0.3)
	≥4 times/wk	381 (99.7)	1 (0.3)	260 297 (99.5)	1387 (0.5)
Regular physical activity (times/wk)	≥5	1746 (99.9)	1 (0.1)	1 114 788 (99.8)	2361 (0.2)
	3–4	3142 (99.8)	6 (0.2)	2 164 594 (99.8)	3678 (0.2)
	1–2	4233 (99.7)	11 (0.3)	2 877 381 (99.7)	8164 (0.3)
	<1	1795 (99.5)	10 (0.5)	1 245 671 (99.7)	8559 (0.3)
	Never exercise	3983 (99.0)	39 (1.0)	2 624 041 (98.9)	27 888 (1.1)
Burnout experience (yes)		4838 (99.4)	31 (0.6)	3 393 173 (99.3)	24 356 (0.7)
Unmet medical needs experience: mental health (yes)		415 (98.1)	8 (1.9)	283 058 (98.2)	5345 (1.8)
Experience with using sleeping pills throughout life (yes)		517 (98.5)	8 (1.5)	378 778 (98.6)	5324 (1.4)
Experience with using tranquilizers throughout life (yes)		557 (98.9)	6 (1.1)	431 684 (99.2)	3717 (0.8)
Self-rated health	Very good	1717 (99.9)	2 (0.1)	1 068 607 (99.9)	1114 (0.1)
	Good	6541 (99.9)	10 (0.1)	4 417 485 (99.9)	6828 (0.1)
	Fair	5643 (99.3)	41 (0.7)	3 839 383 (99.1)	33 334 (0.9)
	Poor	928 (98.7)	12 (1.3)	654 430 (98.7)	8713 (1.3)
	Very poor	70 (97.2)	2 (2.8)	46 569 (98.6)	660 (1.4)
Depression (yes)		9517 (99.5)	53 (0.5)	6 513 175 (99.4)	38 768 (0.6)

Models	OR (95% CI)	p-value
Model 1: Population-weighted unadjusted model	4.76 (2.87, 7.88)	<0.001
Model 2: Population-weighted adjusted model	2.43 (1.37, 4.31)	0.003
Model 3: Population-weighted greedy 1:3 matching	2.03 (1.04, 3.94)	0.037

Models	OR (95% CI)	p-value
Model 4: Population-weighted unadjusted model	5.60 (2.52, 12.43)	<0.001
Model 5: Population-weighted adjusted model	4.15 (1.57, 10.95)	0.004
Model 6: Population-weighted greedy 1:3 matching	3.87 (1.38, 10.85)	0.010