Associations between Physical Activity, Depression, Self-Esteem, and Suicide Ideation in Adolescents

Introduction

Adolescence has been generally defined as a stage integrating biological development, enhancement of socialization, and psychological skills. This synergic transition is important for health-related behaviors and health states in adolescents [1–3].

Mental health (MH) is a significant health issue for adolescents [4,5]. MH is divided into two psychological states: positive (i.e., self-esteem and self-concept, etc.) and negative (i.e., depression, anxiety, and suicidal ideation, etc.) [6–8].

Recently, it has been broadly witnessed that many adolescents are suffering from MH problems [9]. Especially, during COVID-19, a large number of studies have indicated that many adolescents reported higher levels of depression and even suicidal ideation due to family isolation and school closures [10–12]. More seriously, the prevalence of depression and its caused suicide attempts are continuously increasing in the post-COVID-19 [13].

At this point, it has been paid concerted attention to focus on MH and its treatment practices with adolescents in developed countries in developed countries [5]. Furthermore, the current research has been directed toward theoretically based and empirically supported MH care that aimed at identifying the relation to physical activity (PA) in adolescents [14].

PA is one of the health-promoting behaviors and regular PA is significant in preventing negative MH problems [15,16]. It is well documented that regular PA can help promote physical and psychological health for adolescents [17]. Physical activity and mental health are theoretically and empirically associated [18–19]. For example, some studies indicated that a lack of PA is significantly associated with high levels of anxiety, and suicide ideation in adolescents [13,18]. Moreover, other studies reported that regular PA is positively effective in enhancing self-esteem and self-concept [14,19].

A large volume of studies has reported that engaging in PA positively changes negative MH and that PA is a significant predictor to explain depression and suicidal ideation [13,20]. However, some studies indicated that there are no substantial relationships between PA and suicidal ideation [21] as well as suicidal attempts [22]. With such mixed findings, Lester and colleagues argued that the association between PA and suicide ideation could be mediated by further MH variables [23].

If it has been widely agreed that PA is significant in reducing depression and increasing self-esteem, it can be assumed that depression and self-esteem mediate the association between PA and suicide ideation. Some studies have investigated a mediating effect of self-esteem and depression between physical activity and suicide ideation [24,25]. Yu and colleagues indicated that depression and self-esteem have a significant mediating effect in explaining the relationship between PA and suicidal ideation [26]. Additionally, Xiong and the colleagues revealed that PA is significant in reducing depressive symptoms and modulating depression via the mediation of self-esteem [27].

According to these studies, physical activity is directly associated with depression, self-esteem, and suicide ideation, and self-esteem and depression are significant mediators of the relationship between PA and suicide ideation. However, there is limited research that has been carried out to investigate the association between PA, depression, self-esteem, and suicide ideation in Korean adolescents. Most of the previous studies have been conducted in Western countries, while such research is lacking in Korea, where adolescents’ MH promotion through PA participation has been recently paid much attention. Hence, the current study investigated the associations of PA with self-esteem, depression, and suicidal ideation. In addition, this study examined whether self-esteem and depression mediate the link between PA and suicide ideation in adolescents. Fig. 1 is the hypothesized model set in this study, and the research hypotheses were set as follows:

Figure 1: Hypothesized model for explaining the relationship between physical activity, depression, self-esteem, and suicide ideation in adolescents.

Hypothesis 1. PA will be significantly related to self-esteem, depression, and suicide ideation.

Hypothesis 2. Self-esteem and depression will significantly mediate the relationship between PA and suicide ideation.

Materials and Methods

Study participant

A total of 946 adolescents (male: 527, female: 419) aged from 14–19 years old (Mage = 15.78, SD = 2.53) voluntarily participated in this study. In the initial stage of the study, permission from the principal and parents was given. Then, the objectives and procedures of the study were provided through newsletters and the student bulletin board in schools. Through these processes, 998 adolescents completed the survey form. Of these, 52 adolescents were excluded because they did not properly respond. All remaining 946 participants provide their informed consent in compliance with the approval of the Institute of Review Board of Seoul National University of Science and Technology.

Measures

The self-esteem scale, developed by Rosenberg [28], was used in the study. This measure consists of two high-ordered sub-factors with 10 items (positive self-esteem and negative self-esteem with 5 items each). The participants were asked to indicate on a 5-point Likert scale from “not at all” (1) to “very much so” (5), a two-week test-retest reliability was 0.83.

The leisure time physical activity scale (LTEQ), originally developed by Godin et al. [29], was applied in the study to evaluate participants’ habitual weekly PA. Participants were asked to report how many times they engaged in high-intensity (i.e., running and strenuous cycling, etc.), moderate (i.e., fast walking and easy swimming, etc.), and mild (i.e., yoga and golf, etc.) PA for more than 15 min during a typical week. The score was calculated by multiplying each activity session using the following equation. A two-week test-rest reliability was 0.86.

Metabolic equivalent (MET) = [high intensityx9] + [Moderatex5] + [Mildx3]).

*MET stands for the metabolic equivalent of task. One MET is the amount of energy used while sitting quietly. Physical activity may be rated using METs to indicate their intensity. For example, reading may use about 1.3 METs while running may use 8–9 METs

The depression scale (SDS), originally developed by Zung [30], was applied to measure adolescents’ depression. The measure consists of two high-ordered sub-factors with 20 items (positive and negative with 10 items each). The participants responded with a 5-point Likert scale ranging from “not at all” (1) to “repeatedly” (5) for statements such as “I feel best in the morning when I am in the best mood of the day,” (positive) or “I suddenly burst into tears or feel like crying for a long time,” (negative). A two-week test-retest reliability was 0.79.

The suicide ideation scale (SIS) developed by Harlow et al. [31] was applied to measure suicidal ideation in Korean adolescents. This measure consists of 5 questions with a 5-point Likert scale from “not at all” (1) to “repeatedly” (5) for statements such as “I have ever had thoughts about suicide”. The scale asks respondents to rate the frequency of suicidal thoughts and considerations of dying, predictions of future suicidal behavior, experiences of telling others they would kill themselves, and experiences of suicidal prayers. Higher total scores are associated with higher levels of suicidal ideation. A two-week test-retest reliability was 0.89.

Data analysis

The collected data were analyzed by using the SPSS 28. First, descriptive statistics were conducted to summarize the study variables of the participants. Second, a bivariate correlation analysis was conducted to evaluate the degree of relationship between all study variables. Third, Structural Equation Modeling (SEM) was conducted to identify the influences of PA, self-esteem, and depression on suicide ideation. Additionally, SEM was applied to examine the mediating effect of self-esteem and depression in predicting the relationship between PA and suicide ideation. To establish the model fit of the proposed model, some global indexes were applied: a χ2/df ratio less than 3, a relative fit index (RFI), a comparative fit index (CFI), the adjusted goodness of fit index (AGFI) values greater than 0.90, and the root mean square error of approximation (RMSEA) values less than 0.05 [32,33]. All statistical significance was tested at α = 0.05.

Results

Descriptive analysis

Table 1 shows the descriptive statistics (i.e., Mean, Standard Deviation, and Percentage) for the study variables of the participants. According to Table 1. The PA (Mean score of METs) of the study participants was 9.66, adding up mild PA (5.63), moderate (8.09), and vigorous (12.72). In addition, for MH, the mean with SD of self-esteem was 3.04 ± 0.47 67.9% of the study participants experienced depression and 21.7% had suicide ideation.

Correlation analysis

Table 2 presents the bivariate correlation coefficients and descriptive statistics between all study variables. The correlation coefficients between all variables range from 0.20 to 0.71, indicating that they are all statistically significant. In specific, PA was substantially correlated with self-esteem (r = 0.33), depression (r = −0.42), and suicide ideation (r = −0.20). Based on the correlation coefficient, the association among PA, depression, self-esteem, and suicide ideation were considered.

Structural equation model analysis

SEM was conducted to verify the association among PA, depression, self-esteem, and suicide ideation in Hypothesis 1 and 2. As Shown in Table 3, PA is significantly related to self-esteem (β = 0.68, p = 0.001), depression (β = −0.37, p = 0.001), and suicide ideation (β = −0.19, p = 0.001). The relationships between self-esteem esteem and suicide ideation (β = −0.31, p = 0.001) and between depression and suicide ideation (β = 0.46, p = 0.001) were statistically significant. In addition, self-esteem (β = 0.23, CI [0.043, 0.155], p = 0.001) and depression (β = 0.35, CI [0.043, 0.155], p = 0.001) significantly mediated the relationship between PA and suicide ideation.

The current study estimated and tested the relationships among PA, depression, self-esteem, and suicide ideation to establish a model fit. Based on the findings, the proposed model of the present study was suitable for the data with indices of global model fit presented in Table 4. Fig. 2 shows the standardized path coefficients among PA, self-esteem, depression, and suicide ideation.

Figure 2: Relationship of physical activity with depression, self-esteem, and suicide ideation in adolescents (*p < 0.05; **p < 0.01).

Discussion

To well understand the current findings, it is essential to be aware that investigating the role of PA on adolescents’ mental health (i.e., depression and suicide ideation) is significant for several reasons. First, adolescents can contribute to successfully changing their own negative MH through participation in regular PA [34]. Second, by understanding the association between PA and MH processes, more effective PA strategies for adolescent groups that are at high MH risk–may be developed and implemented [35].

To accomplish a deeper understanding of the processes that lead to MH promotion among adolescents, the current study examined the hypothesized model that PA would be associated with self-esteem, depression, and suicide ideation- and that self-esteem and depression would mediate the associations between physical activity and suicide ideation.

The current findings showed that adolescents’ PA had a clear association with self-esteem, depression, and suicidal ideation. This was supported by previous studies, demonstrating that PA reduces depression and suicide ideation and promotes self-esteem [36,37]. Gu conducted a pre- and post-study of adolescents participating in aerobic exercise three times a week for 16 weeks and found that there were statistically substantial differences in MH, with lower levels of depression and anxiety [38]. Mayer found that adolescents who engaged in PA for a longer period had higher self-esteem and lower depression [39]. Moreover, Lee et al. [40] also reported that adolescents who engaged in low- to moderate-intensity regular PA had higher self-esteem and lower depression.

Based on the association of PA with depression and self-esteem identified from the current findings, it can be plausible to suggest that adolescents should be encouraged to be involved in regular PA and provided with more opportunities to participate in various types of PA. Furthermore, it is important to understand that regular PA in adolescents prevents not only physiological and physical problems such as metabolic syndrome (i.e., obesity, type-2 diabetes, high blood pressure, etc.), which are often triggered by excessive study time, but also a variety of MH problems (i.e., stress, depression, and anxiety, etc.).

Moreover, the current findings indicated that PA is statistically significantly related to suicide ideation. This was supported by previous studies, indicating that adolescents who participated in PA reported lower suicidal ideation than non-participants, and the longer they participated in PA, the lower their suicidal ideation [41,42]. However, such a relationship between PA and suicide ideation has not been consistently supported by previous studies [21,22]. Lester et al. argued that the identification of potential mediators of the association between PA and suicide ideation [23]. In this regard, some studies indicated that factors that belong to the negative dimension of MH such as depression, and the positive dimension of MH such as self-esteem may serve as crucial mediators in this relationship [43,44].

The current study from an adolescent population contributes to the clarification of the MH issue. In this study, PA and self-esteem were negatively related to depression and suicide ideation. Moreover, depression and self-esteem significantly mediated the association between PA and suicide ideation, and this finding is supported by previous studies [26,45]. Ha and colleagues reported that PA is significantly related to suicidal ideation through self-esteem and depression demonstrating that self-esteem harmed depression, and depression had a positive effect on suicidal ideation in the PA group compared to the non-PA group [46]. Brailovskaia et al. also indicated that the association between higher PA and lower suicide-related outcomes was substantially mediated by higher self-esteem [43].

Limitations and implications

Several limitations should be considered for further study. The study participants were recruited from three secondary schools in Nowon-gu located in northern Seoul. Therefore, these data may not be representative of all Korean adolescents. The study applied a cross-sectional design, and hence we cannot guarantee a causal relationship among the study variables. Moreover, because the data was obtained from self-reported measures, some biases or prejudices may occur to interpret and recall the items.

Despite these limitations, the current findings clarify that it can be significant to account both for the presence of PA and self-esteem in addition to awareness of risks due to depression, when assessing individuals at risk for suicide. It is a fact that regular PA can not only help the experience of positive feelings and increase the sense of control that individuals with enhanced suicide risk often overlook but also mitigate depression which may significantly influence suicidal ideation and attempts. Therefore, the study suggests that the suicide prevention intervention should incorporate PA involvement with self-esteem and depression to strengthen the protective combined effect of the intervention on suicidal ideation and suicide attempts.

Conclusion

The current study attempted to test the association of PA with depression, self-esteem, and suicide ideation. The findings indicated that adolescents’ PA is significantly associated with self-esteem, depression, and suicidal ideation- and that depression and self-esteem are significantly mediated by the relationship between PA and suicide ideation. These results could not only emphasize the importance of the PA as a protective health behavior against depression and suicide ideation but also accelerate the effective PA intervention targeting adolescents suffering from negative MH problems.

Acknowledgement: We acknowledge all participants involved in this research and those who helped in recruiting.

Funding Statement: This study was supported by the Research Program funded by the SeoulTech (Seoul National University of Science and Technology).

Author Contributions: Youngho Kim designed the study. Nguyen Hoang Minh Thuan and Dojin An collected data. All authors analyzed the data and wrote the manuscript. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials: The raw data supporting the conclusions of this article will be made available by the author, without undue reservation.

Ethics Approval: The studies involving human participants were reviewed and approved by the Research Ethics Committee of Seoul National University of Science and Technology (2023-0024-01). Written informed consent to participate in this study was provided by the participant’s legal guardian.

Conflicts of Interest: The authors declare that they have no conflicts of interest to report regarding the present study.

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