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2024 Korean Neuropsychiatric Association
INTRODUCTION
Since the rst case of coronavirus disease-2019 (COVID-19)
was identied in 2019, the cumulative number of reported
cases worldwide has reached nearly 197 million and the cu-
mulative number of deaths has reached 4.2 million.1 In Ko-
rea, >30 million people (more than 1/2 of the total population
of Korea) have been diagnosed, and about 35,000 people died
from COVID-19 by August 2023.2
eISSN 1976-3026
OPEN ACCESS
As the COVID-19 outbreak continued, the emergence of
associated depressive symptoms, oen referred to as “corona
blues” or “corona depression,” became a signicant concern.3
One meta-analysis reported a high prevalence of depressive
symptoms reaching 33.7% during the COVID-19 pandemic.4
Understanding the depressive symptoms in the context of
the COVID-19 pandemic includes two aspects: COVID-19
infection itself, and social concerns related to COVID-19 in-
fection. Several studies have reported that the prevalence of
depressive symptoms following COVID-19 infection ranges
from 11.5% to 31%.5-7 In addition, as COVID-19 progressed
into pandemic and profound social changes (such as eco-
nomic recession, increased unemployment, and perceived
social stigma) occurred, it is increasingly apparent that indi-
viduals’ depressive symptoms were related to social concerns
arising from the pandemic.8,9
Since the outbreak of the COVID-19 pandemic, many peo-
ORIGINAL ARTICLE
Impact of COVID-19 Infection and Related Social Concerns
on Depressive Symptoms: Mediating Eects of Negative Changes
in Daily Life and Moderating Eects of Age and Gender
Dham Ho1, Sun-Young Kim1, Hye Ah Lee2, Hyunsun Cho3, and Weon-Jeong Lim1
1Department of Psychiatry, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
2Clinical Trial Center, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
3Department of Statistics, Ewha Womans University, Seoul, Republic of Korea
Objective is study examined the mediating eect of negative changes in daily life due to the coronavirus disease-2019 (COVID-19)
pandemic on depressive symptoms, considering COVID-19 infection and related social concerns. Additionally, comparisons of path co-
ecients between the groups were conducted based on age and gender.
Methods A cross-sectional study design used data from the 2020 Korean Community Health Survey consisting of 229,269 individuals.
is study used a self-reported questionnaire, including the Patient Health Questionnaire-9 and three items addressing social concerns
related to COVID-19 infection. A single question assessed whether individuals had experienced COVID-19 infection within the last
3 months, and scores of negative changes in daily life due to the COVID-19 pandemic. Correlation analysis was performed on the vari-
ables. Structural equation model analysis was conducted to identify the mediating role of negative changes in daily life. Chi-square tests
were also performed to compare the path coecients based on age and gender.
Results e structural equation models revealed that COVID-19 infection and related social concerns had both signicant direct eects
on depressive symptoms and indirect eects through negative changes in daily life. When comparing the path coecients by age and gen-
der, the coecients related to depressive symptoms were highest in those under 65 years and in females.
Conclusion Negative changes in daily life due to the COVID-19 pandemic serve as a partial mediator of the impact of COVID-19 infec-
tion and related social concerns on depressive symptoms. Special attention should be paid to depressive symptoms in those under 65 years
of age and in females. Psychiatry Investig 2024;21(12):1318-1328
Keywords Depressive symptom; COVID-19; Social concern; Daily life change; Korean Community Health Survey.
Received: May 7, 2024 Revised: September 7, 2024
Accepted: October 26, 2024
Correspondence: Weon-Jeong Lim, MD, PhD
Department of Psychiatry, Ewha Womans University Seoul Hospital, Ewha
Womans University College of Medicine, 260 Gonghang-daero, Gangseo-gu,
Seoul 07804, Republic of Korea
Tel : +82-2-6986-1676, Fax: +82-2-6986-3066, E-mail: psyweon@ewha.ac.kr
cc is is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (https://creativecommons.org/licenses/by-
nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited.
https://doi.org/10.30773/pi.2024.0159
D Ho et al.
www.psychiatryinvestigation.org 1319
ple have experienced changes in their daily lives due to quar-
antines and social distancing to reduce community spread.10
These changes have included restrictions on public gather-
ings, distance education in schools, reduced work hours or
closure of on-site work, and limited access to community sup-
port. Such disruptions have increased vulnerability to mental
health problems.8,11 Studies have shown that concerns about
COVID-19 and COVID-19 infection also played a signicant
role in negative changes in daily life.6,9 Subsequently, these
negative changes in daily life are recognized as a factor that
elevates the risk of developing depressive symptoms.8 ere-
fore, it can be hypothesized that negative changes in daily life
due to the COVID-19 pandemic may mediate the eects of
COVID-19 infection and related social concerns regarding
depressive symptoms. However, there is little evidence that
supports whether negative changes in daily life due to the
COVID-19 pandemic mediate the eects of COVID-19 in-
fection and related social concerns on depressive symptoms.
In terms of sociodemographic factors, demographic vari-
ables associated with depressive symptoms showed differ-
ences before and during the COVID-19 pandemic.12,13 In a
study comparing risk factors for depressive symptoms before
and during the COVID-19 pandemic, the prevalence of de-
pressive symptoms was approximately 1.5 times higher in fe-
males both before and during the pandemic.3 Although the
COVID-19 pandemic aected both males and females equal-
ly and led to a signicant increase in prevalence of depressive
symptoms, the male-to-female ratio was not signicantly dif-
ferent from that observed before the pandemic.3,4 Addition-
ally, the risk of depressive symptoms was higher among
younger age groups during the pandemic, diering from pre-
pandemic trends.3 erefore, further stratication of the anal-
ysis by age and gender may help to better understand these
risk factors during the COVID-19 pandemic.3 Regarding
gender dierences, females are generally at higher risk for de-
pression both before and during the COVID-19 pandemic.3
Recent studies suggest that females may have had a higher
prevalence of depression during the COVID-19 pandemic due
to previously recognized hormonal eects14 and psychosocial
factors such as reduced social activity and increased caregiv-
er burden.15 Additionally, younger age groups, identied as a
risk factor during the COVID-19 pandemic,3 who are more
socially active, may have experienced a greater impact on
their daily lives and perceived greater social role pressure in
the pandemic.16,17
From this perspective, this study used a structural equation
model to investigate the impact of COVID-19 infection and
related social concerns on depressive symptoms, as well as
the mediating role of negative changes in daily life. In addi-
tion, we conducted subgroup analysis, examined moderation
effects, and compared path coefficients based on age and
gender.
METHODS
Participants
is study utilized data from the 2020 Korean Community
Health Survey (KCHS) conducted by the Korea Centers for
Disease Control and Prevention (KCDC).18 e KCHS data-
set is publicly available from the Centers for Disease Control
and Prevention website (https://chs.kdca.go.kr/chs/rawDta/
rawDtaProvdMain.do). Since 2008, this survey has been a
collaborative eort between survey teams from universities
and public health centers in compliance with the Communi-
ty Health Act and involving local communities. e data col-
lection involved a two-step sampling process. Initially, sample
regions within each district (Dong/Eup/Myeon) were selected
based on the number of households categorized by housing
type (apartment/detached house) using probability propor-
tional sampling. Subsequently, households within the chosen
sample regions were selected using systematic sampling. Ap-
proximately ve households per region were included. e
survey was conducted through face-to-face interviews with
adults aged 19 years and older. It included various factors such
as health behaviors, quality of life, socio-environmental fac-
tors, and healthcare utilization. From August 16 to October 31,
2020, trained investigators visited the selected households and
conducted one-on-one interview surveys. e survey ques-
tionnaire consisted of a total of 142 items divided into 18 sec-
tions. is study included a substantial sample size of 226,765
participants. e KCHS protocol was approved by the Insti-
tutional Review Board of the KCDC (2016-10-01-P-A).
Assessment
Sociodemographic questionnaires
e general characteristics were gender (male and female),
age group (<65 years and ≥65 years), marital status (never
married, married, divorced, and widowed), education level
(less than elementary school, middle school diploma, high
school diploma, or college degree or higher), employment sta-
tus (yes or no), physician-diagnosed hypertension (yes or no),
and physician-diagnosed diabetes mellitus (yes or no).
Depressive symptoms
Depressive symptoms were measured using the Patient Health
Questionnaire-9 (PHQ-9), which is a self-reported depression
screening instrument that was developed by Spitzer et al.19 It
comprises the following nine items: anhedonia, depressed
mood, sleep problems, fatigue, appetite change, feelings of
1320 Psychiatry Investig 2024;21(12):1318-1328
Impact of COVID-19 on Depressive Symptoms
worthlessness and self-deprecation, concentration diculties,
psychomotor agitation, thoughts of suicide and self-harm.
Each item is rated on a 4-point Likert scale from 0 “not at all”
to 3 “nearly every day”. e total score is a simple summation
of all item scores, where a higher total score indicates a high-
er level of depressive symptoms. e Cronbach’s α coecient
for the depression items of PHQ-9 was 0.826 in this study.
Social concerns related to COVID-19 infection
e latent variable of social concerns related to COVID-19
infection consisted of the following three observed variables:
“I’m concerned that if I get infected with COVID-19, I’ll face
blame or harm from those around me;” “I’m concerned that
if I get infected with COVID-19, vulnerable individuals in
my family, such as the elderly, children, or those with existing
health issues, might get infected with COVID-19;” and “ I’m
concerned about the economic impact of the COVID-19
pandemic on both myself and my family, including concerns
about job loss or nancial diculties if I get infected with
COVID-19.” Each item was rated on a 5-point Likert scale from
1 “very much” to 5 “ not at all” and was reverse-scored. A high-
er score indicates a higher level of concern related to COV-
ID-19 infection.
COVID-19 infection
Being quarantined or hospitalized due to COVID-19 in-
fection was represented by a positive response to the ques-
tion, “Have you ever been quarantined or hospitalized for
COVID-19 infection within the last 3 months?”
Negative changes in daily life due to the COVID-19
pandemic
Negative changes in daily life due to the COVID-19 pan-
demic were assessed through direct scoring, as follows: “In
comparison to your daily life before the COVID-19 pandem-
ic, where 100 points represents the pre-pandemic state and 0
points indicates a complete standstill of daily activities, what
would you rate your current situation?” e scale employed
10-point intervals, with reverse scoring applied. A score of 0
denoted no change in daily life compared to that of the pre-
COVID-19 pandemic, while 100 signied a complete cessation
of daily activities. Higher scores indicated a more signicant
negative impact on daily life due to the COVID-19 pandemic.
Statistical analysis
All analyses were conducted in R soware (version 4.3.1).
Descriptive statistical analyses were conducted to identify the
means and standard deviations of the clinical characteristics.
A correlation analysis was performed to explore whether the
variables included in our models were correlated aer con-
trolling for age and gender. p values <0.05 were considered
signicant. We performed structural equation modeling us-
ing the lavaan package to examine whether COVID-19 infec-
tion within the preceding three months and social concerns
about COVID-19 infection impacted PHQ-9 scores through
mediation of negative changes in daily life due to the COV-
ID-19 pandemic. The structural equation model was con-
trolled for age, gender, marital status, and employment status.
In addition to the previously mentioned risk factors, individ-
uals with preexisting conditions of hypertension or diabetes
mellitus, who are at higher risk for severe COVID-19 symp-
toms, may experience increased depression due to lifestyle
changes, such as spending more time at home and reduced
social interaction due to fears of infection.3,20,21 erefore, phy-
sician-diagnosed hypertension and diabetes mellitus, as pre-
existing medical conditions that could inuence depression
during the COVID-19 pandemic, were included as covariates
in the analysis. e tness of the model was assessed using
the Root Mean Square Error of Approximation (RMSEA),
Comparative Fit Index (CFI), Goodness Fit of Index (GFI),
and Tucker-Lewis Index (TLI). RMSEA values of 0.05 or low-
er indicated a close t. e RMSEA should ideally be between
0.02 and 0.07, and the CFI and TLI should be >0.90.22 e
signicance of the indirect eects was tested using the boot-
strapping method with 500 re-samples.
Two-subgroup analyses with Satorra-Bentler scaled chi-
squared tests and two-sample Z-tests were also conducted by
categorizing the sample into age groups (under 65 years and
65 years or older) and gender groups (male and female). ese
subgroup analyses were used for the following reasons: to
verify whether the model is statistically signicant in each of
the subgroups, to explore potential dierences in the eects
of COVID-19 infection and social concerns about COVID-19
infection on depressive mood and negative changes in daily
life, and to compare the estimated coecients of latent vari-
ables and paths coecients between the groups. If a Z-score
was >1.96 or <-1.96, it was considered statistically signicant
at the 5% signicance level.23
RESULTS
Demographic statistics and correlation analysis
Descriptive statistics were performed using frequency and
proportion for basic characteristics in statistical analysis. e
demographic characteristics and clinical questionnaire scores
are presented in Table 1 as female (54.7% of the sample), age
under 65 years (68.2%), married (65.6%), employed (60.6%),
physician-diagnosed hypertension (27.9%), physician-diag-
nosed diabetes mellitus (11.7%), and COVID-19 infection
within the preceding 3 months (0.5%). e prevalence of de-
D Ho et al.
www.psychiatryinvestigation.org 1321
pressive symptoms, dened as PHQ-9 score of 10 or higher,
was 3.1%. e results of the correlation matrices of clinical
and controlled variables are presented in Table 2. Moderate
correlations were observed only among the three variables
related to social concerns about COVID-19 infection. Re-
garding the social concerns about COVID-19 infection, con-
cern about surrounding blame positively correlated with con-
cern about infection of vulnerable individuals (r=0.4721,
p<0.001) and concern about economic impact (r=0.4120, p<
0.001). Concern about infection of vulnerable individuals pos-
itively correlated with concern about economic impact (r=
0.4888, p<0.001). Scores of negative changes in daily life due
to the COVID-19 pandemic (COVID-NCDL) were weakly
positively correlated with concerns about surrounding blame
(r=0.0981, p<0.001), concern about infection of vulnerable
individuals (r=0.1021, p<0.001), and concern about economic
impact (r=0.1233, p<0.001).
Mediation model between COVID-19 infection,
social concerns about COVID-19 infection, negative
changes in daily life due to the COVID-19 pandemic,
and depressive mood
e results of the mediating eects of negative changes in
daily life due to the COVID-19 pandemic on the association
between COVID-19 infection, social concerns about COV-
ID-19 infection, and depressive mood are shown in Table 3
and Figure 1. Table 3 presents the unstandardized coecients,
standard errors, the statistical signicance of the direct and
indirect eects, and standardized coecients. e paths are
presented in Figure 1, including the corresponding standard-
ized coefficients. The model demonstrated a good fit (
χ
2=
7,069.380, df=25.000, p<0.001, CFI=0.952, TLI=0.913, RM-
SEA=0.037, GFI=0.987) with controlling age, gender, marital
status, employment status, physician-diagnosed hypertension,
and physician-diagnosed diabetes mellitus. The structural
equation model showed signicant direct eects of the two
independent variables (social concern of COVID-19 infec-
tion, COVID-19 infection within the last 3 months) on the
outcome (PHQ-9 scores). e direct eects were statistically
signicant (all p values<0.01), including the eect of nega-
tive changes in daily life due to the COVID-19 pandemic on
PHQ-9 (β=0.063, p<0.001).
Moderation by age in the mediation model
For analysis by age, we rst divided individuals younger than
65 years into two groups: those younger than 45 years (young
adults) and those aged 45 years and older (mid adults). We
then compared the path coecients between these two age
groups. Since there were few signicant dierences between
the groups, we combined them into a single group (under 65
years old), performed subgroup analysis, and compared the
path coecients with those of individuals aged 65 years or
older. As a result, the model t for the under 65 years group
showed χ2=4,453.702, df=22.000, p<0.001, CFI=0.948, TLI=
0.905, RMSEA=0.038, and GFI=0.988. For the 65 years or old-
Table 1. Demographics characteristics of participants and survey
scores
Demographic information Value
Gender
Female 125,375 (54.7)
Male 103,894 (45.3)
Age group (yr)
Under 45 67,701±29.5
45 to 64 88,756±38.7
65 or older 72,812±31.8
Marital status
Married 150,322 (65.6)
Never married 40,356 (17.6)
Divorced 10,642 (4.6)
Widowed 27,827 (12.1)
Employment status (currently working)
Yes 138,970 (60.6)
No 90,236 (39.4)
Hypertension diagnosed by physician
Yes 64,008 (27.9)
No 165,208 (72.1)
Diabetes mellitus diagnosed by physician
Yes 26,835 (11.7)
No 202,381 (88.3)
COVID-19 infection within last 3 months
Yes 1,073 (0.5)
No 228,196 (99.5)
Depressive symptoms, dened as PHQ-9 score of 10 or higher
Yes 7,029 (3.1)
No 222,240 (96.9)
Clinical characteristics [range]
PHQ-9 [027] 1.96±2.95
Scores of negative changes in daily life due
to COVID-19 pandemic [0100]
44.71±23.16
Social concerns about COVID-19 infection
Concern about surrounding blame [15] 3.99±1.02
Concern about infection of vulnerable
individuals [15]
4.31±0.87
Concern about economic impact [15] 4.11±1.02
Data are presented as mean±standard deviation or number (%).
COVID-19, coronavirus disease-2019; PHQ-9, Patient Health Ques-
tionnaire-9
1322 Psychiatry Investig 2024;21(12):1318-1328
Impact of COVID-19 on Depressive Symptoms
er group, the model t resulted in χ2=1,288.856, df=22.000,
p<0.001, CFI=0.978, TLI=0.960, RMSEA=0.029, and GFI=
0.992, demonstrating a good model fit in both age groups.
Structural equation models for each age group (under 65 years
and 65 years or older) are shown in Figure 2.
e constrained model for measurement coecients dem-
onstrated a good t (χ2=5,859.562, df=51.000, p<0.001, CFI=
0.959, TLI=0.936, RMSEA=0.033, GFI=0.999). ere were
signicant dierences in the coecient estimates of the la-
tent variables between the under 65 years and 65 years or
older groups (χ2=7.315, p=0.026). e constrained model for
structural coecients, which examined whether the path co-
ecients between the variables across groups are equal, ex-
hibited a good fit (χ2=6,300.015, df=61.000, p<0.001, CFI=
0.956, TLI=0.943, RMSEA=0.031, GFI=0.999). Additionally,
it was conrmed that there is a moderating eects of gender
among path coecients between the two groups (χ2=440.450,
p<0.001).
e comparison of path coecients of the structural mod-
el between the two groups, along with the Z-test results, esti-
mates, and standard errors, are presented in Table 4. Among
the group aged 65 years or above, the only path that showed
a higher estimate compared to those under 65 years was CO-
VID-19 infection COVID-NCDL (Z score=-3.2021). Other
Table 2. Correlation matrix among variables (social concerns related to COVID-19 infection, COVID-NCDL, PHQ-9 and COVID-19 infection
within the last 3 months) after controlling for gender and age
1234567
Social concerns about COVID-19 infection
1. Concern about blame -
2. Concern about transmission of vulnerable
individuals
0.4721*** -
3. Concern about economic impact 0.4120*** 0.4888*** -
4. COVID-NCDL 0.0981*** 0.1021*** 0.1233*** -
5. PHQ-9 0.0234*** 0.0508*** 0.0504*** 0.0704*** -
6. COVID-19 infection -0.0008 0.0000 -0.0070*** 0.0148*** 0.0074*** -
7. Gender 0.1270*** 0.0816*** 0.0678*** 0.0552*** 0.1102 -0.0017*** -
8. Age 0.1138*** 0.0796*** 0.1103*** -0.1317*** 0.0355*** -0.04231*** 0.0531***
*p<0.05; **p<0.01; ***p<0.001. COVID-19, coronavirus disease-2019; COVID-NCDL, scores of negative changes in daily life due to the CO-
VID-19 pandemic; PHQ-9, Patient Health Questionnaire-9
Table 3. Direct and bootstrap indirect effects in the multiple mediational models for PHQ-9 scores
Unstandardized
β coecient (SE) Z-value pStandardized
β coecient
Direct eects
Social concerns PHQ-9 0.209 (0.013) 16.316 <0.001*** 0.045
COVID-19 infection PHQ-9 0.297 (0.103) 2.873 0.004** 0.007
Social concerns COVID-NCDL 6.150 (0.089) 69.496 <0.001*** 0.169
COVID-19 infection COVID-NCDL 3.327 (0.724) 4.596 <0.001*** 0.010
COVID-NCDL PHQ-9 0.008 (0.000) 25.031 <0.001*** 0.063
Indirect eects
Social concerns COVID-NCDL PHQ-9 0.051 (0.002) 23.853 <0.001*** 0.011
COVID-19 infection COVID-NCDL PHQ-9 0.033 (0.006) 5.479 <0.001*** 0.001
Total indirect eect 0.084 (0.007) 12.142 <0.001*** 0.012
Total eect of path
Social concerns COVID-NCDL PHQ-9 0.049 (0.002) 23.147 <0.001*** 0.011
COVID-19 infection COVID-NCDL PHQ-9 0.027 (0.006) 4.500 <0.001*** 0.001
Total eect of all paths 0.582 (0.105) 5.531 <0.001*** 0.063
All direct and indirect eects were adjusted by age, gender, marital status, employment status, and diagnosis of hypertension and diagnosis of
diabetes mellitus. *p<0.05; **p<0.01; ***p<0.001. COVID-NCDL, scores of negative changes in daily life due to the COVID-19 pandemic;
Social concerns, social concerns related to COVID-19 infection; PHQ-9, Patient Health Questionnaire-9
D Ho et al.
www.psychiatryinvestigation.org 1323
paths such as COVID-NCDL PHQ-9 (Z score=13.3250),
COVID-19 infection PHQ-9 (Z score=6.5253), social con-
cerns PHQ-9 (Z score=5.4280), and social concerns CO-
VID-NCDL (Z score=8.9900) all indicated higher estimates
for those under 65 years old than in those 65 years and older.
Moderation by gender in the mediation model
e results of subgroup analysis by gender show that for
Concern about
surrounding blame
Concern about infection
of vulnerable individuals
Concern about
economic impact
COVID-19 infection
within the last 3 months
Negative changes
in daily life due to
COVID-19 pandemic
Depressive symptoms
(PHQ-9)
0.632***
0.742***
0.659*** 0.169***
0.010***
0.007***
0.045***
0.063***
Social concerns about
COVID-19 infection
Figure 1. Structural equation model for PHQ-9 controlled by age, gender, marital status, employment status, physician-diagnosed hyper-
tension, and physician-diagnosed diabetes mellitus. All coefcients are standardized. *p<0.05; **p<0.01; ***p<0.001. COVID-19, coronavirus
disease-2019; PHQ-9, Patient Health Questionnaire-9.
Concern about
surrounding blame
Concern about infection
of vulnerable individuals
Concern about
economic impact
COVID-19 infection
within the last 3 months
Negative changes
in daily life due to
COVID-19 pandemic
Depressive symptoms
(PHQ-9)
0.669***
0.805***
0.701*** 6.4699***
3.4686***
0.4237**
0.2244***
0.0101***
Social concerns about
COVID-19 infection
A
Concern about
surrounding blame
Concern about infection
of vulnerable individuals
Concern about
economic impact
COVID-19 infection
within the last 3 months
Negative changes
in daily life due to
COVID-19 pandemic
Depressive symptoms
(PHQ-9)
0.610***
0.714***
0.636*** 5.4267***
5.9179**
-0.2113
0.1450***
0.0055***
Social concerns about
COVID-19 infection
B
Figure 2. Structural equation models for age (A) under 65 years old (B) 65 years and older controlled by gender, marital status, employ-
ment status, physician-diagnosed hypertension, and physician-diagnosed diabetes mellitus. *p<0.05; **p<0.01; ***p<0.001. COVID-19, coro-
navirus disease-2019; PHQ-9, Patient Health Questionnaire-9.
1324 Psychiatry Investig 2024;21(12):1318-1328
Impact of COVID-19 on Depressive Symptoms
males, the model t yielded χ2=2,855.159, df=22.000, p<0.001,
CFI=0.955, TLI=0.917, RMSEA=0.037, GFI=0.988. For fe-
males, the model t resulted in χ2=2,021.258, df=22.000, p<
0.001, CFI=0.974, TLI=0.952, RMSEA=0.028, and GFI=0.993,
indicating a good model t in both groups. Structural equa-
tion models for each gender group are shown in Figure 3.
e constrained model for measurement coecients dem-
onstrated a good t (χ2=6,013.767, df=51.000, p<0.001, CFI=
0.957, TLI=0.933, RMSEA=0.033, GFI=0.999). ere were
significant differences in the coefficient estimates of latent
variables between males and females (χ2=10.624, p=0.005).
e constrained model for structural coecients exhibited a
good t (χ2=6,324.052, df=61.000, p<0.001, CFI=0.955, TLI=
0.941, RMSEA=0.031, GFI=0.999). In addition, we found that
there is a moderating eect of age among path coecients be-
tween the two groups (χ2=310.29, p<0.001).
e comparison of path coecients of the structural mod-
el between the two groups, along with the Z-test results, esti-
mates, and standard errors, are presented in Table 4. When
differences in path coefficients between male and female
groups were examined, the estimate for the social concerns
COVID-NCDL path was signicantly larger in males than it
was in females (Z score=5.2173). In contrast, the estimates for
the paths of COVID-NCDL PHQ-9 (Z score=-11.2580) and
social concerns PHQ-9 (Z score=-5.8327) were signicant-
ly larger in females than they were in males.
DISCUSSION
In this study, both COVID-19 infection and related social
concerns were signicantly positively associated with depres-
sive symptoms, the prevalence of which was 3.1%. Previous
research on the prevalence of depressive symptoms during
the early COVID-19 pandemic has reported gures ranging
from 11.2% to 27.8%.3,11,24 e variation in prevalence may be
attributed to dierences in infection rates, regulations, and
perceptions of mental health problems across countries.3
However, given that a 2018 KCHS conducted by the KCDC
reported a prevalence of depressive symptoms of 2.8%, the
observed increase in prevalence is consistent with previous
research ndings.5-7,25 Our ndings are also consistent with
previous research indicating that higher COVID-19-infec-
tion-related social concerns, including economic impact, blame,
and transmission to vulnerable family members, are linked to
increased levels of depressive symptoms.26-28
Using a structural equation model, we discovered that both
COVID-19 infection and related social concerns indirectly
influenced depressive symptoms through negative changes
in daily life caused by the COVID-19 pandemic.
Each of the three social concerns may result in depressive
Table 4. Comparison of path coefcients in structural equation models based on age (under 65 years old, 65 years and older) and gender
Age Gender
Age <65 Age ≥65 Z test Male Female Z test
bSE bSE Z score p b SE bSE Z score p
COVID-NCDL PHQ-9 0.0101 0.0003 0.0055 0.0002 13.3250 <0.001 0.0056 0.0004 0.0099 0.0004 -11.2580 <0.001
COVID-19 infection PHQ-9 0.4237 0.0973 -0.2113 0.2600 6.5253 <0.001 0.2468 0.1229 0.3362 0.1373 -0.7276 0.045
Social concerns PHQ-9 0.2244 0.0146 0.1450 0.0212 5.4280 <0.001 0.1647 0.0157 0.2562 0.0181 -5.8327 <0.001
COVID-19 infection COVID-NCDL 3.4686 0.7649 5.9179 2.0042 -3.2021 <0.001 2.9087 1.0556 3.7120 1.0011 -0.7610 0.006
Social concerns COVID-NCDL 6.4699 0.1160 5.4267 0.1638 8.9900 <0.001 6.5649 0.1358 5.8563 0.1323 5.2173 <0.001
COVID-NCDL, scores of negative changes in daily life due to COVID-19 pandemic; Social concerns, social concerns related to COVID-19 infection; PHQ-9, Patient Health Questionnaire-9
D Ho et al.
www.psychiatryinvestigation.org 1325
symptoms through negative changes in daily life. For instance,
concern about economic loss if one is infected with COV-
ID-19 is likely to be associated with job absence and inability
to complete one’s tasks.29,30 In this situation, individuals may
have an economic concern regarding the potential nancial
instability caused by COVID-19 infection. Job instability re-
sulting from COVID-19 infection can lead to nancial stress
and disruption of routines and social relationships, potentially
contributing to depressive symptoms.31
Second, an individual may have concerns about the blame
associated with contracting COVID-19. When the risk of a
disease increases due to non-compliance with government
infection prevention policies, there is a tendency to blame the
victim’s morality.30 During the COVID-19 pandemic, South
Korea assessed people’s morality based on adherence to so-
cial distancing rules, such as wearing face masks, avoiding
crowded places, and openly sharing their travel history.32 e
result showed that such concerns could lead to the potential-
ly mistaken belief that non-compliance with government in-
fection prevention policies, perceived as immoral behavior, was
the cause of the infection.33 In addition, East Asians with a
background in Confucianism may be more concerned about
criticism from those around them due to work absence from
COVID-19 infection.34 erefore, in the process of keeping
social distancing for avoiding blame with COVID-19 infec-
tion, people may view others as asymptomatic carriers or as
potentially contaminated. Diminished personal and social
trust can prompt defensive behaviors, resulting in restrictions
in daily life and a reduction in social interactions.35 Conse-
quently, this may give rise to emotional challenges such as
frustration, boredom, lethargy, and loneliness.36 On a physical
level, daily life restrictions may result in reduced physical ac-
tivity or changes in circadian rhythm, which can also lead to
depressive symptoms.8
Lastly, individuals may have concerns about transmission
of COVID-19 infection to vulnerable family members, in-
cluding the elderly, children, and patients with disease, who
may have a higher risk of severe symptoms, morbidity, and
mortality with COVID-19 infection.37 is problem may be
more pronounced in South Korea, where the proportion of
Figure 3. Structural equation models for (A) males and (B) females controlled by age, marital status, employment status, physician-diag-
nosed hypertension, and physician-diagnosed diabetes mellitus. *p<0.05; **p<0.01; ***p<0.001. COVID-19, coronavirus disease-2019; PHQ-9,
Patient Health Questionnaire-9.
Concern about
surrounding blame
Concern about infection
of vulnerable individuals
Concern about
economic impact
COVID-19 infection
within the last 3 months
Negative changes
in daily life due to
COVID-19 pandemic
Depressive symptoms
(PHQ-9)
0.673***
0.802***
0.701*** 6.5649***
2.9087***
0.2468***
0.1647***
0.0056***
Social concerns about
COVID-19 infection
A
Concern about
surrounding blame
Concern about infection
of vulnerable individuals
Concern about
economic impact
COVID-19 infection
within the last 3 months
Negative changes
in daily life due to
COVID-19 pandemic
Depressive symptoms
(PHQ-9)
0.607***
0.717***
0.636*** 5.8563***
3.7120***
0.3362***
0.2562***
0.0099***
Social concerns about
COVID-19 infection
B
1326 Psychiatry Investig 2024;21(12):1318-1328
Impact of COVID-19 on Depressive Symptoms
the elderly population has been steadily increasing since 2001.38
In an eort to prevent the infection of vulnerable populations
within families, restrictions on social interactions and daily
activities are imposed on both the vulnerable individuals and
their families, which potentially makes vulnerable people more
dependent on their families.39 Especially during the early stag-
es of the COVID-19 pandemic in 2020, the lack of remote sys-
tems for social support and access to health services exacer-
bated caregivers’ physical and mental health, which contributed
to caregiver burden and burnout.40 is situation may ulti-
mately lead to depressive symptoms among caregivers of vul-
nerable populations.39,40
Our results showed that negative changes in daily life are
closely associated with depressive symptoms. During the CO-
VID-19 infection period, individuals undergoing isolation
may have experienced heightened psychological distress and
depressive symptoms.41 Moreover, constraints on visitation
and reduced social support may have exacerbated these symp-
toms.42 Workers, especially those in transportation, food, per-
sonal care, and service occupations, may have experienced
heightened stress and economic issues during the infection
period.29 These stressors may lead to increased negative
changes in daily life and potentially contribute to depressive
symptoms. COVID-19 survivors oen suer reduced muscle
strength, joint mobility, and respiratory capacity, along with
somatic symptoms like pain and dyspnea.43 All of these side
eects can signicantly impair both basic activities of daily liv-
ing and instrumental activities of daily living.43,44 Such de-
creases in activities of daily living can diminish autonomy,
independence, self-esteem, and quality of life, potentially con-
tributing to depressive symptoms.44
In this study, the total eect of social concerns (including
economic problems, fear of infecting vulnerable individuals,
and social blame for COVID-19 infection) had a greater im-
pact on depressive symptoms than did COVID-19 infection
itself. Our data represent the early stages of the COVID-19
pandemic, which was characterized by high mortality and
morbidity but relatively low infection rates,45,46 as well as the
absence of vaccines or treatments, strict infection prevention
policies,47,48 and a rapid economic recession.49 erefore, these
results may indicate that fear of COVID-19 infection during
the early stages of the pandemic may be signicantly associ-
ated with depressive symptoms.
Furthermore, in this model, subgroup analyses were con-
ducted based on gender and age. When comparing path co-
ecients by age, the impact of COVID-19 infection on nega-
tive changes in daily life was more signicant in those aged 65
years or older than it was in younger individuals. ese nd-
ings are consistent with the results of a previous study, indi-
cating that elderly patients experience a higher severity of CO-
VID-19 infection, resulting in a greater prevalence of long-term
sequelae and an impact on their quality of life.5,50 Although
older adults are more vulnerable to the virus, the path coe-
cients associated with depressive symptoms and those from
social concerns about COVID-19 infection to negative chang-
es in daily life were notably larger in the group under 65 years
than they were in the group aged 65 years or older. is nd-
ing is consistent with recent research results suggesting that
young people may experience higher rates of depressive symp-
toms than older individuals,16,17,51 possibly due to social role
pressures resulting from factors such as career and academic
demands.16,17 Additionally, young adults may be more vulner-
able to the eects of the COVID-19 pandemic due to factors
such as greater media exposure, the impact of nancial crises,
managing workload responsibilities, and less eective coping
strategies compared to older adults.11
Regarding gender, the path coecient for social concerns
about COVID-19 infection inuencing negative changes in
daily life due to the COVID-19 pandemic was larger in males
than in females. While males tend to experience greater daily
life changes because of their more frequent engagement in so-
cial activity compared to females,52 it is noteworthy that the
path coecient related to depressive symptoms was larger in
females than in males. is suggests that depression in females
may be more signicantly aected by concerns and negative
life changes associated with COVID-19, explaining for the
observed gender dierence in COVID-19-related depression.
ese ndings are consistent with previous research showing
that females are signicantly aected psychologically by the
COVID-19 pandemic.16,17,53 Although objective risks such as
COVID-19 morbidity and mortality are higher in males, emo-
tional responses are more pronounced in females.54 is sug-
gests that factors beyond the severity of COVID-19 infection
may inuence emotional reactions. During the COVID-19
pandemic, females were more concerned about family health
and well-being than were males;15 therefore, females’ predom-
inant role as family caregivers may increase their vulnerability
to social isolation and distress.14,55 Additionally, from a bio-
logical standpoint, females tend to have larger endocrine, af-
fective, and arousal responses to stress than males, which may
lead to a greater susceptibility to social isolation.14
is study has several limitations. First, this study is the
cross-sectional design; therefore, the results are exploratory
and should be interpreted with caution. While there were dif-
ferences in lifestyle and prevalence of depressive symptom be-
tween the pre-pandemic and pandemic periods, there were
also shis in these patterns during the pandemic due to vari-
ations in COVID-19 policy intensity and perceptions of the
disease.3,56 erefore, it may be dicult to generalize the nd-
ings of this study, as the survey was conducted during a peri-
D Ho et al.
www.psychiatryinvestigation.org 1327
od of few COVID-19 infections and, as a cross-sectional study,
may not fully capture these changes. Second, only a self-re-
ported evaluation scale was used to evaluate psychological
symptoms. Objective and structured interviews were not con-
ducted, making it dicult to ensure the objectivity and valid-
ity of the psychiatric conditions reported. Use of a self-rated
0100 scale to measure negative changes in daily life may not
fully reect all types of negative changes experienced by indi-
viduals. ird, despite adherence to personal hygiene rules
by interviewers and participants (such as hand disinfection,
mask-wearing, and social distancing), many people did not
voluntarily participate in the survey, indicating selection bias.
Overall, this study is the rst to examine the mediating ef-
fect of negative changes in daily life on the impact of COV-
ID-19 infection and related social concerns on depressive
symptoms in South Korea using structural equation model-
ing. Our ndings demonstrate that social concerns about CO-
VID-19 infection have a more signicant impact on depres-
sive symptoms than does COVID-19 infection itself. e large
sample size of this study enhances its generalizability, and sub-
group analyses based on age and gender underscore the im-
portance of tailored interventions to address depressive symp-
toms during the COVID-19 pandemic. Lastly, another strength
of this study is its reection of the general population, espe-
cially considering that individuals aged 65 years and older
represented 16.4% of the total population in 2020.57
Availability of Data and Material
e datasets generated or analyzed during the study are available from
the corresponding author on reasonable request.
Conflicts of Interest
e authors have no potential conicts of interest to disclose.
Author Contributions
Conceptualization: Weon-Jeong Lim. Data curation: Weon-Jeong Lim.
Funding acquisition: Weon-Jeong Lim. Investigation: Dham Ho, Sun-Young
Kim. Methodology: Dham Ho, Sun-Young Kim, Hye Ah Lee, Hyunsun Cho.
Project administration: Weon-Jeong Lim. Soware: Hyunsun Cho. Super-
vision: Sun-Young Kim. Writing—original dra: Dham Ho. Writing—re-
view & editing: all authors.
ORCID iDs
Dham Ho https://orcid.org/0000-0001-8963-754X
Sun-Young Kim https://orcid.org/0000-0003-3705-9746
Hye Ah Lee https://orcid.org/0000-0002-4051-0350
Hyunsun Cho https://orcid.org/0000-0002-4337-2192
Weon-Jeong Lim https://orcid.org/0000-0002-2100-4233
Funding Statement
This work was supported by the Ewha Womans University Research
Grant of 2024.
Acknowledgments
We acknowledge the fundings that support our study and the partici-
pants involved in this study.
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