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. 2025 Oct 14;25:984. doi: 10.1186/s12888-025-07454-3

Anxiety and depression as mediators in insomnia-suicidal ideation link among isolated individuals

Xiaofei Mao 1,#, Fan Zhang 1,#, Chunyan Ni 2,#, Qiong Zhou 2,✉, Tianya Hou 1,✉
PMCID: PMC12522656  PMID: 41088087

Abstract

Objective

Isolation in Fangcang shelter hospitals during Shanghai lockdown may exacerbate mental health problems or even suicide risk. This study aimed to examine the mediating effects of anxiety and depression in the relationship between insomnia and suicidal ideation.

Methods

Participants were recruited via convenience sampling method. A total of 461 individuals completed the cross-sectional assessments, which was designed to measure demographic information, Insomnia, anxiety, depression, and suicidal ideation.

Results

All variables of interest were positive and significant associated with each other (all P < 0.01). Anxiety fully mediated role between insomnia and suicidal ideation, accounting for 62.65% of the total effect. Similarly, depression also acted as a fully mediator in this relationship, with a mediating effect of 77.11%.

Conclusion

Insomnia was associated with an increased risk of suicidal ideation, with anxiety and depression serving as full mediators in this relationship. Targeted interventions addressing insomnia, anxiety, and depressive symptoms should be implemented to mitigate and potentially prevent suicidal ideation among isolated individuals.

Keywords: Anxiety, Depression, Insomnia, Suicidal ideation, Mediation

Highlights

• Anxiety played a fully mediating role in the insomnia-suicidal ideation link.

• Depression was a fully mediator in the association between insomnia and suicidal ideation.

• This study shed light on the possible psychological mechanisms of the linkage between insomnia and suicidal ideation.

Introduction

Widespread infection of COVID-19 occurred in Shanghai, China in February 2022. To decrease the spread of the virus, the Chinese government convened medical staffs and built Fangcang shelter hospitals to treat patients infected with COVID-19. Shanghai stepped into the period of city lockdown since then (involving business closures, restrictions on domestic movements, and stay at home orders) [25]. Isolation was proved to be related to mental problems among people in Fangcang shelter hospitals during Shanghai lockdown [49]. For instance, [52] revealed a moderate prevalence of depression (12.2%) and anxiety (13.3%) among infected children in a Fangcang shelter hospital during Shanghai lockdown. Besides, results based on patients with COVID-19 in Fangcang shelter hospitals during Shanghai lockdown showed that positive screening rates for anxiety, depression, and insomnia were 55.3%, 27.0%, and 47.8%, respectively [35]. Moreover, Isolation was identified as an independent risk factor of suicide risk [11]. Researchers found that isolation emerged as a significant risk factor for suicide during the COVID-19 pandemic. For example, [14] supposed that COVID-19 and its consequences such as isolation may lead to the emergence of suicidal thoughts. In line with this finding, Escobar-Córdoba and colleagues found that people were more likely to have suicidal ideation in conditions of social isolation during the COVID-19 pandemic [16]. Therefore, we could infer that suicidal ideation among isolated individuals was a vital issue during Shanghai lockdown.

Bhat et al. [8] summarized the association between COVID-19 and sleep dysfunction and concluded that the COVID-19 pandemic had a profound impact on sleep quality. Plenty of literature demonstrated that effects of lockdown during COVID-19 pandemic on sleep problems among subjects from different countries [13, 23, 32, 45]. Evidently, sleep difficulty became a widespread public health concern in the context of city lockdown.

Insomnia was proved to be closely related to suicidal risk from solid evidence [1–3, 6, 7]. In a meta-analysis by Pigeon et al. [36], sleep disturbance was significantly correlated with the increased relative risk for suicidal ideation. Besides, a prospective cohort study based on 75,000 Norwegian adults indicated that baseline sleep problems were closely related to the subsequent risk of suicide [9]. Winsper and Tang pointed out that a strong correlation between insomnia and suicide has been observed in clinically depressed and anxious populations in their review [47]. In the context of COVID-19, sleep abnormalities were supposed to be a stand-alone risk factor for suicidal ideation [38, 39]. Meanwhile, sleep quality could predict the development and persistence of suicidal ideation in a two-wave longitudinal survey during COVID-19 pandemic [46]. Therefore, we supposed that insomnia may be a risk factor of suicidal ideation.

Scholars reviewed literature focusing on the insomnia-suicide link [24, 47]. They emphasized the roles of hopelessness, dysfunctional beliefs and attitudes about sleep, and the deficit of decision making in the association between insomnia and suicide risk in their reviews. However, the previous research findings about the potential psychological mechanisms of the insomnia-suicide link were inconsistent. The psychological mechanisms between insomnia and suicidal ideation were still unclear and should be investigated further.

Prior studies found that anxiety and depression were closely associated with the insomnia-suicide link. For example, a two-decade longitudinal study demonstrated that sleep disturbances served as a significant predictor of suicide risk, primarily mediated by the co-occurrence of sleep disorders with comorbid anxiety and depressive symptoms [9]. Meanwhile, insomnia may have a negative influence on anxiety and depression [43]. Mao et al. conducted a longitudinal study of non-clinical young Chinese adult males, they found that insomnia was a predictive factor of anxiety [26]. Subjects with insomnia had more problems of anxiety and depression than those without insomnia, and were 17.35 and 9.82 times as likely to suffer from anxiety and depression, respectively [44]. Robust association between insomnia and suicide was observed in clinically anxious and depressed participants, which indicated that anxiety and depression may play important roles between insomnia and suicidal ideation [47]. A study based on COVID-19 patients in China revealed that anxiety and depression symptoms were mediators between sleep quality and suicide risk. Specifically, the more severe the sleep quality, the more it triggered depressive and anxious symptoms, which may increase the possibility of suicide risk [50]. Besides, a cross-sectional study conducted during COVID-19 lockdown in Greece found that anxiety and depression symptoms were associated with higher odds of suicidal ideation [34].

Therefore, we could infer that anxiety and depression may play mediating roles between the relationship between insomnia and suicidal ideation.

Given the evidence of the close relationships among insomnia, anxiety, depression, and suicidal ideation, it is of great importance to classify the associations during Shanghai lockdown. However, studies concerning the associations among these variables were still limited. To address this gap, we intended to conduct a study aiming to reveal the mediating roles of anxiety and depression in the insomnia-suicidal ideation link among subjects with isolation experience in Fangcang shelter hospitals during Shanghai lockdown. It may inform us with potential measures to reduce or even prevent suicidal ideation among subjects with isolation experience, such as improving sleep quality and intervening in their anxiety and depression.

We hypothesized that anxiety and depression played mediating roles between insomnia and suicidal ideation among subjects with isolation experience in Fangcang shelter hospitals during Shanghai lockdown. A mediation model was constructed to test our hypotheses (See Fig. 1).

Fig. 1.

Fig. 1

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Conceptual framework of hypothesized model

Methods

Study design and participant recruitment

This cross-sectional investigation was implemented in Shanghai, China in May 2022, Eligible participants met the following inclusion criteria: (a) absence of reading disorders, (b) minimum age of 18 years, and (c) isolated in Fangcang shelter hospital during Shanghai lockdown. Individuals with pre-existing mental health conditions were excluded from participation. Using a convenience sampling approach, 461 eligible subjects were enrolled. Data collection was performed electronically via the Chinese survey platform “Wenjuanxing” (https://www.wjx.cn/). The research protocol received prior ethical clearance from the Institutional Review Board of Suzhou Hospital, Nanjing University Medical School (Protocol No. IRB201912002RI). All participants provided informed consent after being fully informed about the study’s objectives, their right to withdraw without consequence, and the guaranteed confidentiality of their responses. To ensure the safety and well-being of participants, immediate psychological counseling support was provided on-site by trained mental health professionals to any individual who reported active suicidal ideation during the survey. Additionally, all such participants were referred to specialized crisis intervention services and provided with continued psychological follow-up as necessary. The participant enrollment process is visually detailed in Fig. 2.

Fig. 2.

Fig. 2

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The participant enrollment process

Assessment measures

Sociodemographic characteristics

The research protocol incorporated comprehensive demographic data collection, capturing key variables such as: Biological sex (male/female), Chronological age (in years), Educational attainment (total years of formal schooling), Marital status (categorized as single, married).

Anxiety symptom assessment

The Generalized Anxiety Disorder-7 (GAD-7) instrument, developed by Spitzer and colleagues [42], serves as a psychometrically robust measure for anxiety symptom screening and severity quantification in both clinical and research settings. This standardized 7-item questionnaire evaluates the frequency of anxiety-related manifestations over a 14-day recall period, with response anchors comprising: 0 = “Not at all”, 1 = “Several days”,2 = “More than half the days”, 3 = “Nearly every day”. Psychometric evaluations have established the measure’s strong reliability and validity in Chinese populations [27, 29], with the current study demonstrating excellent internal consistency (α = 0.94).

Depressive symptoms measurement

The Patient Health Questionnaire-9 (PHQ-9), developed based on DSM-IV diagnostic criteria [41], assesses depressive symptomatology through nine items rated on a four-point frequency scale (0 = never to 3 = nearly daily) with a two-week recall window. Previous validation studies have confirmed its psychometric robustness in Chinese samples [12, 30], with the current dataset showing good internal consistency (α = 0.87).

Sleep disturbance evaluation

Insomnia severity was measured using the 7-item Insomnia Severity Index (ISI; [4]), which employs a five-point Likert scale (0–4) to evaluate subjective sleep impairment. The Chinese adaptation has demonstrated strong reliability and validity [28, 31], with excellent internal consistency in this study (α = 0.94).

Suicidal ideation assessment

Current suicidal ideation was evaluated through a single-item measure (“I thought about killing myself”) with three response categories (never/sometimes/often) referencing the past month. This assessment approach has been widely implemented in suicide research [20].

Analytical approach

The data analysis was performed using IBM SPSS Statistics (v24.0) with the PROCESS macro (v3.4.1) extension. All statistical tests employed a two-tailed approach with the significance threshold established at p < 0.05. The analytical procedure consisted of two primary components: correlational analysis and mediation analysis. Bivariate relationships among study variables were examined using Pearson’s product-moment correlation coefficients. As to the mediation analysis, indirect effects were evaluated through bias-corrected bootstrapping with 5,000 iterations. Mediation was considered statistically significant when the 95% confidence intervals (95% CI) of the indirect effects excluded zero.

Results

Demographic characteristics

461 participants were recruited with convenience sampling method. The average age of our subjects was 32.80 ± 8.64 years old, and the average years of education was 14.76 ± 3.09 years. 53.35% of the respondents (247) were female, and 40.35% of our subjects (186) were single.

Pearson’s correlation analyses

The descriptive statistics and correlations among insomnia, anxiety, depression, and suicidal ideation were listed in Table 1. The results showed that all variables of interest were positively and significantly associated with each other (all P < 0.01).

Table 1.

Descriptive statistics and correlations among variables

Variables Mean ± SD Anxiety Depression Insomnia Suicidal Ideation
Anxiety 2.18 ± 3.44 1
Depression 4.56 ± 4.19 0.74** 1
Insomnia 6.68 ± 5.54 0.55** 0.64** 1
Suicidal Ideation 1.03 ± 0.20 0.32** 0.32** 0.23** 1
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**P < 0.01

Mediation analysis

Mediation analysis was performed by PROCESS 3.4.1 (Model 4) after controlling the confounders (age, gender, years of education, and marital status) with insomnia as independent variable, anxiety/depression as mediating variable, and suicidal ideation as dependent variable. The mediating models were presented in Figs. 3 and 4.

Fig. 3.

Fig. 3

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Mediating role of anxiety between insomnia and suicidal ideation (***P < 0.001)

Fig. 4.

Fig. 4

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Mediating role of depression between insomnia and suicidal ideation (***P < 0.001)

Mediating role of anxiety

The direct effect of insomnia on suicidal ideation value was 0.0031 [95%CI = (−0.0006 ~ 0.0069)], suggesting the direct effect wasn’t significant. The indirect effect value of anxiety was 0.0052 [95%CI = (0.0012 ~ 0.0119)], indicating that indirect effect was significant. Thus, anxiety played a fully mediating role between insomnia and suicidal ideation. The mediating effect accounted for 62.65% of the total effect.

Mediating role of depression

Similarly, the direct effect of insomnia on suicidal ideation value was 0.0019 [95%CI = (−0.0022 ~ 0.0060)], suggesting the direct effect wasn’t significant. The indirect effect value of anxiety was 0.0064 [95%CI = (0.0014 ~ 0.0134)], indicating that indirect effect was significant. Thus, depression played a fully mediating role between insomnia and suicidal ideation. The mediating effect accounted for 77.11% of the total effect.

Disscusion

Suicide continued to be a leading cause of death globally, highlighting the critical need to identify risk factors [48]. The current study revealed that anxiety and depression played fully mediating roles between insomnia and suicidal ideation.

In line with prior studies [5, 7], we found insomnia was associated with suicidal ideation significantly. For example, Pigeon et al. [36] pointed out that insomnia was a risk factor of prospective suicide based on publications with longitudinal designs in their systematic review. Meanwhile, [38, 39] suggested interventions focusing on sleep problems were extremely important in reducing rates of suicides during COVID-19 pandemic. Wang and colleagues revealed that sleep disturbance could predict the development and persistence of suicidal thoughts among 67,905 college students in China during COVID-19 pandemic [46].

We also demonstrated the mediating roles of anxiety and depression between the insomnia-suicidal ideation link. Specifically, anxiety and depression fully mediated the association between insomnia and suicidal thought during Shanghai lockdown, respectively. Our results indicated that insomnia indirectly influenced suicidal ideation via anxiety symptoms, which was consistent with previous studies. Korean researchers found that anxiety played a fully mediating role in the linkage between insomnia and suicidal ideation in patients with adjustment disorder [21]. Meanwhile, Chinese scholars revealed that anxiety symptoms acted as a mediating role between insomnia and suicide risk in COVID-19 patients [50]. According to the result of the mediating role of depression, we could infer a potential pathway from insomnia to suicidal ideation via depression. Several recent research revealed similar results among different samples. For example, mediation analysis with bootstrapping demonstrated that depression fully accounted for the link between insomnia and suicidal ideation in young adults [19]. Meanwhile, a pathway from insomnia to suicidal ideation via depression was found among adolescents in Shanghai, China [51]. Furthermore, mediation analyses across three clinical samples of US military personnel demonstrated that depression significantly mediated the relationship between insomnia severity and suicidal ideation [10].

The present study investigated the mediating roles of depression and anxiety in the association between insomnia and suicidal ideation among isolated subjects during Shanghai lockdown, which shed light on the possible psychological mechanisms of the linkage between insomnia and suicidal ideation. As proposed by Winsper et al. [47] and McCall et al. [24], hopelessness, dysfunctional beliefs and attitudes about sleep, and impaired decision-making capacity acted vital roles in the insomnia-suicide association. However, extant evidence remains inconclusive regarding these psychological mechanisms, particularly in explaining how insomnia contributes to suicidal ideation, warranting further investigation. Strong associations between insomnia and suicide were consistently observed among clinically anxious and depressed individuals [40, 47], suggesting that anxiety and depression may serve as significant mediators in the insomnia-suicidal ideation pathway. Meanwhile, robust relationships among insomnia, anxiety, depression and suicidal ideation were observed during the COVID-19 pandemic [17, 22, 38, 39]. Efstathiou and colleagues investigated the risk factors of suicidal ideation during COVID-19 lockdown in Greek [15, 18, 34]. They pointed out that depression, anxiety, and mental health history were associated with higher incidence of suicidal thought.

While the associations between insomnia, anxiety, depression, and suicidal ideation have been previously documented, the distinct experience of individuals under enforced isolation during public health crises remains underexplored. To our knowledge, this is the first study to examine the mediating roles of anxiety and depression in the relationship between insomnia and suicidal ideation specifically within a population subjected to lockdown-induced isolation.

Our findings contribute to the existing literature by uncovering the psychological mechanisms that underlie this association in a unique and high-risk group, thereby extending current theoretical frameworks to acute crisis settings. This focus enhances the practical relevance of our study, particularly for designing targeted interventions during public health emergencies. The results suggest that integrated psychological support addressing insomnia, anxiety, and depression simultaneously may offer an effective strategy for reducing suicidal ideation among isolated populations.

Implications

We considered relevant implications for enriching the possible psychological mechanisms of the insomnia-suicidal ideation and identifying potential preventive measures to eliminate or even prevent suicidal thoughts among isolated individuals. Our results provided empirical information about the relationships among insomnia, anxiety, depression, and suicidal ideation among the isolated populations. Insomnia could indirectly predict suicidal thoughts through the mediating role of anxiety or depression. Moreover, we enriched the psychological mechanisms of the linkage between insomnia and suicidal ideation. It was emphasized that anxiety and depression played vital roles in the insomnia-suicidal ideation link, suggesting potential intervention plans focusing on the promotion of insomnia, anxiety, and depression needs to be designed to reduce or prevent suicidal risks.

Limitations

Several limitations of the present study were listed as follows. First, causal relationships among variables couldn’t be determined based on the cross-sectional design in our study. Longitudinal studies are needed to derive possible causal relationships. Secondly, the sample size based on convenience sampling method was relatively small, which may limit the generalizability of our results. We recommend future study to expand their sample size. Thirdly, this study utilized a convenience sample consisting exclusively of individuals isolated in Fangcang shelter hospitals during the Shanghai lockdown. While this approach provided timely access to a relevant population under crisis conditions, it may introduce selection bias and limit the extrapolation of findings to broader or more diverse settings. The results are likely most applicable to individuals experiencing similar forms of isolation during public health emergencies. Therefore, caution should be exercised when generalizing these conclusions to other populations or non-crisis contexts. Furthermore, suicidal ideation was assessed using a single-item measure. Although this method is pragmatically advantageous in large-scale surveys, it may lack the sensitivity, specificity, and diagnostic depth offered by multi-item scales or clinician-administered instruments. This limitation could potentially influence the accuracy and comprehensiveness of the identified associations. We therefore recommend that future studies employ more comprehensive and validated tools, such as structured clinical interviews or established multi-item scales, to improve the reliability and nuance of suicide-related assessments.

Conclusion

Insomnia was significantly associated with a higher risk of suicidal ideation. The relationship was fully mediated by anxiety and depression. Targeted interventions addressing insomnia, anxiety, and depressive symptoms should be implemented to mitigate and potentially prevent suicidal ideation among isolated people.

Acknowledgements

The authors would like to acknowledge the volunteers who participated in the study. They also wished to honor their late friend Nan Xia, a devoted high school teacher who passed away in 2021. May he rest in peace.

Authors’ contributions

Xiaofei Mao, Fan Zhang and Chunyan Ni collected the data, analyzed the data and drafted the manuscript. Qiong Zhou and Tianya Hou designed and led the whole study. All the authors have read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Suzhou Key Medical Discipline Support Project (SZFCXK202109); 2022 Suzhou Nursing Society Research Project (SZHL-A-202204).

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All participants signed written informed consent form in ethics approval and consent to participate. Participants were assured their responses were anonymous and confidential and were free to withdraw at any time without penalty. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving human subjects were approved by the ethic committee of Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University (IRB201912002RI).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Xiaofei Mao, Fan Zhang and Chunyan Ni are first authorships equally.

Contributor Information

Qiong Zhou, Email: 838455237@qq.com.

Tianya Hou, Email: liumi9512@126.com.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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