Influence of the Big Five personality traits and the Wuxing of traditional Chinese medicine on depression in adolescents

Abstract

BACKGROUND:

Depression is a worldwide problem, and depressive symptoms are common in adolescence. The global point prevalence rate of elevated self-reported depression is higher than in any other age group. Therefore, it is necessary to pay attention to the depression in adolescents.

MATERIALS AND METHODS:

16- to 18-year-old Chinese adolescents without prior psychiatric diagnoses were recruited from a high school. The students completed SDS and NEO-FFI. Based on the date of birth (DOB) following Innate Wuxing and Qi, descriptive statistics, χ² tests, Spearman correlations, multiple linear regression, and logistic regression were conducted to explore the correlation between depression and Wuxing.

RESULT:

The prevalence of depression was 25.7% and was significantly higher in girls than in boys (33.6% vs. 41.8%, P < 0.01). Depressive symptoms were positively associated with Neuroticism (β =0.354, P < 0.001) and Openness (β =0.093, P < 0.01), and negatively associated with Extraversion (β = −0.303, P < 0.001), Agreeableness (β = −0.138, P < 0.001), and Conscientiousness (β = −0.112, P < 0.001). Wuxing analysis showed that higher scores for Wood (rho = −0.308, P < 0.05) in boys and Fire (rho = −0.237, P < 0.05) in girls were correlated with lower levels of depression.

CONCLUSION:

These results provide a theoretical basis for diagnosis and treatment of depression in adolescents using an integrated psychology and TCM approach.

Introduction

Depression is a worldwide problem, and depressive symptoms are common in adolescence.[1] The global point prevalence rate of elevated self-reported depression is as high as 34% in adolescents, higher than in any other age group.[2] The diagnostic criteria for depression in adolescents are essentially the same as those in adults; however, symptom presentation may vary with developmental stage, and some adolescents may have difficulty recognizing and describing their internal mood states.[3] Depression is a major risk factor for suicide and self-injury during adolescence, and adult depression can begin during puberty, highlighting the need for early identification of adolescent depression and intervention.[4,5] Physiological changes during adolescence may influence the prevalence of depression. In late adolescence, the prevalence of depression is twice as high in girls as in boys, and adolescents aged 15–19 years are more likely to experience suicidal thoughts and suicide attempts.[6,7] Adolescent depression can lead to academic difficulties, peer interaction problems, family problems, and substance abuse and dependence.[8] Adolescent depressive symptoms often lead to depression and other psychological problems in adulthood.[9] The etiology of depression can be categorized according to genetic, biological, and social factors.[7] According to Beck,[9] depression is not just an affective disorder, but also a disorder of negative emotions and self-defeating behaviors driven by anomalous beliefs and maladaptive information processing. Depressive symptoms are associated with a wide range of psychosocial and developmental factors and are influenced by genetic and environmental factors and their interaction. Modifiable risk factors need to be identified to enable the prevention and treatment of depression in adolescents.[10,11,12,13]

Personality traits influence physiological responses and reactions to stressful situations.[14] Maladaptive arrangements of stable and enduring traits and basic personality traits can be used in the study of personality psychopathology.[15] Introverted individuals are predisposed to primary depression.[16] Personality plays an important role in depression because some personality traits are associated with depressive symptoms.[17] Taking personality into account can maximize the effectiveness of treatment for depression.[18]

Understanding the effects of cultural factors on mental health can also improve the treatment of depression in adolescents.[4] The symptoms of depression differ by country and culture. According to traditional Chinese medicine (TCM) theory, depression (known as “Yu”) is triggered by a blockage of the meridians linking the internal organs, which inhibits the Qi (energy) flow to each organ, leading to stagnation.[19] Depression is the main clinical manifestation of a class of diseases characterized by depression of emotions. The ancient natural sciences of Yin-Yang and Wuxing have traditionally been used to explore the natural conditions that nurture life.[20] In TCM, the five organs of the liver, heart, lung, spleen, and kidney correspond to the Wuxing (five elements) of Tree, Fire, Metal, Earth, and Water, respectively. According to TCM, disease is caused by Qi stagnation, and Qi stagnation in the organs can have many different manifestations.[21] Yin-Yang determines the nature of Qi, and Wuxing determines the flow of Qi.[20] Qi and Wuxing are dynamically balanced.

Adolescent depression can have an adverse effect on adolescent development. This study assessed the effects of the Big Five personality traits and the Wuxing of TCM on depression in adolescents, to identify modifiable risk factors and formulate effective preventive measures and intervention strategies.

Materials and Methods

Study design and setting

This study adopted a mixed cross-sectional and longitudinal design, in which both a single-time-point survey and a follow-up cohort were conducted to adolescent depression.

Study participants and sampling

This study included Chinese adolescents aged 16–18 years with no prior psychological diagnoses. The participants were recruited from a high school in Jilin Province, in northeastern China. Participants and their parents were informed in advance about the main objectives of the study, and participation was voluntary with parental consent. The children completed a self-report and questionnaire in the classroom during school hours.

Data collection tool and technique

Depression was measured using the Self-Rating Depression Scale (SDS), which consists of 20 items, 10 positive and 10 negative. Participants were asked to report the frequency of each item on a four-point scale. The scores of each item were summed to obtain a total crude score (X) ranging from 20 to 80, and the standardized score (Y) was obtained by multiplying the crude score by 1.25 and rounding the result to the nearest integer. According to the Chinese normative model, the cutoff value of the SDS standardized score is 53, with 53–62 indicating mild depression, 63–72 indicating moderate depression, and 73 or more indicating severe depression. In this study, the Cronbach’s alpha of the SDS was 0.86, demonstrating high internal consistency and reliability.

The Social Support and Life Hope Scale, consisting of 5 items (α =0.74) and one lie detector question from the Minnesota Multiphasic Personality Inventory, was used to assess participants’ perceived social support and their sense of life hope.

The NEO-Five Factor Inventory (NEO-FFI) was used to measure the five broad domains of personality: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness. Each of the five domains was divided into two facets and scored on a five-point Likert scale. In this study, the Cronbach alpha coefficients were 0.54, 0.65, 0.47, 0.69, and 0.63 for Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness, respectively, demonstrating high internal consistency and reliability.

Chinese civilization has influenced the Chinese psyche and styles of behavior since ancient times, shaping the unique social behaviors and personalities of Chinese people. Chinese psychological behaviors and personality traits are culture-specific; therefore, we focused on the relationship between the localized Chinese personality and the Wuxing and Qi flow. In TCM, the health of the internal organs is reflected in a person’s complexion. Wuxing refers to the movement of the Wuxing. TCM utilizes Wuxing to explain the physiological functions of the human body, to illustrate pathological changes within the organism, and for the diagnosis and treatment of diseases. Wuxing is the embodiment of Yin-Yang.[22] The doctrine of Yin-Yang mainly explains the interdependence, mutual growth, and mutual transformation of complementary opposites, whereas the doctrine of the Wuxing uses five attributes and the birth date to illustrate the attributes of things and the interrelationships between things. In TCM, the term “transportation” refers to the flow of the Wuxing (Tree, Fire, Earth, Metal, and Water) within the body. Qi (vital energy) is involved in the regulation of the six climates (Air, Hot, Heat, Wet, Dry, and Cold), which are environmental factors. Wuxing refers to the operation of the Qi and is categorized into five cycles: inter-promoting, inter-regulating, overacting, weakening, and counteracting.[22]

We applied the Wuxing theory based on the date of birth (DOB) and the time of administration of the questionnaire: Wuxing was projected based on the DOB, representing innate factors, and Qi was projected based on the date on which the questionnaire was administered, representing the influence of environmental factors. These two factors were weighted to calculate the main elements of the Wuxing. The Wuxing scores were applied to indicate the influence of innate and environmental factors on the participant.

Ethical consideration

The study was approved by the Medical Ethics Committee of the Beijing University of Chinese Medicine.

Statistical analysis method

Initially, we performed descriptive statistics of the variables. We compared categorical variables by level of depression using Chi-square tests and measured the correlation between continuous variables using Spearman’s correlation coefficient. Next, we performed multiple linear regression using the lm function, with the SDS score as the dependent variable and the Big Five Inventory (BFI) score as an independent variable, to assess the personality traits that may influence the degree of depression. The glm() function was used to perform logistic regression with SDS status as the dependent variable and the criterion scores of the personality quintiles as the independent variables, to calculate odds ratios (OR) with 95% confidence intervals and assess the associations between personality and depression. Two-tailed P values < 0.05 were considered statistically significant. All of the above analyses were performed in R 4.4.0.

Results

Participant characteristics

1570 Chinese adolescents (52.29% female and 47.71% male) aged 16-18 years old were surveyed using a cross-sectional research method.

Factors associated with depression

We assessed the effect of gender, age, and school grade on the prevalence of depression. The prevalence of depression was significantly higher in girls than in boys, especially during the first year of high school, and the prevalence of depression gradually increased with age. The prevalence of depression differed significantly by grade, but did not differ significantly by age [Table 1].

Table 1.

Mental health results

Factors		Sample No.		Healthy				χ 2		P		Light				Moderate				Severe
				Cases No.		%						Cases No.		%		Cases No.		%		Cases No.		%
Total		1570		975		62.10						400		25.48		154		9.81		41		2.61
Gender
Male		749		497		66.36		11.009		0.001***		174		23.23		58		7.74		20		2.67
Female		821		478		58.22						226		27.53		96		11.69		21		2.56
Age
16		603		381		63.18		0.938		0.626		155		25.70		52		8.62		15		2.49
17		760		471		61.97						189		24.87		81		10.66		19		2.50
18		207		123		59.42						56		27.05		21		10.14		7		3.38
Grade
Freshman		915		573		62.62		0.253		0.615		227		24.81		89		9.73		26		2.84
Sophomore		655		402		61.37						173		26.41		65		9.92		15		2.29
Grade
Freshman
-Age
16		603		381		63.18		0.872		0.647		155		25.70		52		8.62		15		2.49
17		311		191		61.41						72		23.15		37		11.90		11		3.54
18		1		1		100.00						0		0.00		0		0.00		0		0.00
-Gender
Male		446		303		67.94		10.499		0.001**		101		22.65		30		6.73		12		2.69
Female		469		270		57.57						126		26.87		59		12.58		14		2.99
Sophomore
-Age
17		449		280		62.36		0.586		0.444		117		26.06		44		9.80		8		1.78
18		206		122		59.22						56		27.18		21		10.19		7		3.40
-Gender
Male		303		194		64.03		1.673		0.196		73		24.09		28		9.24		8		2.64
Female		352		208		59.09						100		28.41		37		10.51		7		1.99
Lie
Yes		93		66		70.97		3.302		0.069		20		21.51		6		6.45		1		1.08
No		1477		909		61.54						380		25.73		148		10.02		40		2.71
Hopeful
Yes		1544		971		62.89		24.517		<0.001***		397		25.71		148		9.59		28		1.81
No		26		4		15.38						3		11.54		6		23.08		13		50.00
Social support
Yes		1564		974		62.28		5.283		0.022*		400		25.58		153		9.78		37		2.37
No		6		1		16.67						0		16.67		1		16.67		4		66.67

*P<0.05, **P<0.01, ***P<0.001

Hope (i.e., family warmth, peer relationships, and hope for life) was strongly correlated with depression, whereas perceived social support (i.e., family, friends, classmates, and other people around them supporting and actively seeking help) was weakly but significantly correlated with depression.

Figure 1 shows a weighted network diagram of the correlation of depression with gender, age, grade, hope for life, social support, personality, and the Wuxing. Depression was correlated with gender and grade, but not with age. Depression was not correlated with feelings of hope for life and social support, but was correlated with lying in the response to the lie detection question. Depression was correlated with Openness, but not with the other four personality traits, and was not associated with the Wuxing.

Figure 1.

Network diagram of the correlation of depression

Association between Big Five personality traits and depression

Linear regression using the BFI as independent variables confirmed the importance of personality in predicting depression [Table 2]. Of the BFI variables, participants’ ability to manage negative emotions was the most important predictor, followed by interpersonal relationships. Each of the Big Five personality traits was significantly associated with depression: Higher Neuroticism and Openness scores were associated with higher SDS scores (P < 0.001), whereas higher Extraversion, Agreeableness, and Conscientiousness scores were associated with lower SDS scores (P < 0.001). Multivariate linear regression showed that all BFI scores were significantly positively or negatively correlated with the SDS score.

Table 2.

SDS score with BFI influence

Personality traits		Healthy						Mann–Whitney U test				Multiple Linear Regression
		Yes		No		P		SDS score		P		β		P
Neuroticism
< Median		405 (80.52%)		98 (19.48%)		<0.001***		45.45±8.94		<0.001***		0.354		<0.001***
≥ Median		399 (47.73%)		437 (52.27%)				53.95±10.83
Extraversion
< Median		246 (46.95%)		278 (53.05%)		< 0.001***		54.56±11.03		<0.001***		-0.303		<0.001***
≥ Median		558 (68.47%)		257 (31.53%)				48.31±10.20
Openness
< Median		407 (64.50%)		224 (35.50%)		0.002**		49.56±10.90		<0.001***		0.093		0.006**
≥ Median		397 (56.07%)		311 (43.93%)				51.82±10.92
Agreeableness
< Median		295 (46.38%)		341 (53.62%)		< 0.001***		54.01±10.82		<0.001***		-0.138		<0.001***
≥ Median		509 (72.40%)		194 (27.60%)				47.81±10.24
Conscientiousness
< Median		322 (50.47%)		316 (49.53%)		< 0.001***		53.03±10.85		<0.001***		-0.112		<0.001***
≥ Median		482 (68.76%)		219 (31.24%)				48.69±10.66

**P<0.01, ***P<0.001

To further characterize the relationship between the level of depression and personality in the depressed group, we applied the Chi-square test to analyze the distribution of different levels of depression across the five personality traits [Table 3]. Neuroticism and Agreeableness were significantly associated with depression level (P < 0.001).

Table 3.

Depression levels across the five personality traits

Personality		Mean Rank						χ 2		P
		Light n=358		Medium n=140		Heavy n=37
Neuroticism		248.22		300.42		336.76		28.572		<0.001***
Agreeableness		291.48		235.37		164.31		41.484		<0.001***
Openness		264.32		266.30		310.00		8.235		0.083
Extraversion		278.04		250.02		238.89		5.968		0.202
Conscientiousness		275.64		249.9		262.53		7.122		0.130

***P<0.001

Linear regression analysis showed that Extraversion, Agreeableness, and Conscientiousness were significantly negatively associated with depression (P < 0.001), and Neuroticism and Openness were significantly positively associated with depression (P < 0.001) [Figure 2].

Figure 2.

Depression with five personality traits results

Association between the Wuxing and depression

We applied the Wuxing to analyze the subject’s primary elements based on the DOB and the time of questionnaire testing. Correlation analysis was conducted with depression based on the results of the Wuxing of Qi movement to identify high-risk subgroups and the time of onset of depression in adolescents. The Wuxing of adolescents was associated with depression [Table 4]. Further Spearman correlation analysis showed a significant negative correlation between Tree and SDS scores in boys (rho = -0.308, P < 0.05), and between Fire and SDS scores in girls (rho = -0.237, P < 0.05).

Table 4.

Wuxing and depression analysis results

Wuxing		Healthy		Depression		χ 2		P		Boys				Girls
										rho		P		rho		P
Fire		193		147		9.583		0.048*		0.168		0.230		-0.237		0.022*
Metal		183		130						-0.068		0.633		0.07		0.541
Tree		223		129						-0.308		0.021*		-0.061		0.610
Water		246		130						0.109		0.445		-0.018		0.873
Earth		188		144						0.119		0.312		0.038		0.753

*P<0.05

Discussion

We focus on adolescent depression was assessed by personality traits and the Wuxing of TCM. The study shows that the prevalence of depression was significantly higher in girls than in boys; Depression was positively associated with Neuroticism and Openness; Depression was negatively linked to Extraversion, Agreeableness, Conscientiousness. Wuxing of TCM found that higher Tree scores in boys and Fire scores in girls were correlated with lower risk.

Depression is common and is the leading cause of disability and death in adolescents and a major contributor to the overall global burden of disease.[23,24] More than half of the population will meet the criteria for a depressive disorder at some point in their lives, with the first episode usually in childhood or adolescence.[25] Individuals with major depressive disorder with preadolescent onset have a higher risk of suicide attempts and bipolar disorder in adulthood.[26] Prevention or early intervention measures need to focus on youth to reduce the risk of depression in adulthood.[5] Depression detection and intervention needs to be multifaceted, including risk assessment, psychoeducation, psychotherapy, and medication, and interventions that address contributory factors.[27] Individuals with adolescent-onset major depressive disorder have substantial morbidity and increased risk of suicide in adulthood.[28] Physiological and psychological factors are important in the development of depression during adolescence.[29] The prevalence of major depression increases significantly throughout adolescence, with a significantly greater increase in girls than in boys.[23] The SDS is one of the scales recommended by the U.S. Department of Education, Health and Welfare for use in psychopharmacological research.[30] Because it is easy to use and can fairly intuitively reflect an individual’s subjective feelings of depression and response to treatment, it is currently widely used in outpatient screening for depression, assessment of mood states, as well as in surveys and scientific research. Therefore, we applied this scale to assess depression in adolescents.

In this study, the prevalence of depressive symptoms was nearly 40%, and the prevalence of severe depression was 2.6%. These results are consistent with those of previous studies.[23,31]

Personality traits play an important role in predicting depression.[32] The hierarchical structure of adolescent personality traits has similarities and differences from that of adult personality traits.[33] With increasing age, self-reported personality traits typically become more consistent within domains and better differentiated across domains.[34] Hierarchical stability of personality traits increases in early adolescence and plateaus in adulthood.[35] Thus, the transitional phase of adolescence is a critical stage for the stabilization of personality formation. The personality scale is widely accepted because it strikes a good balance between content coverage and brevity.[36,37] Personality traits are usually assessed using scales that summarize responses to questionnaire items in a simple linear combination.[37] The BPT serves as a comprehensive, robust, and parsimonious model with a normal distribution, providing basic information about an individual[38] that is useful in personality research. Previous research has shown that personality has a clinically significant effect on depression.[39] The BPT has been used in various cultures, and in this study, we studied personality and depression in Chinese adolescents from a TCM cultural perspective. Personality traits can be used as markers of the risk of developing major depression.[40] Therefore, interventions that focus on modifying personality traits could potentially be used to treat adolescent depression.

Some of the results were not statistically significant in the multivariate analysis; however, they may still be clinically, psychologically, and biologically significant, even if they are not statistically significant. It is the persistent and extensive validation that advances the progress of research on the correlation between depression and personality, and we also know from case reports that better clinical results have been obtained by applying cognitive therapies in psychology. Studies of patients with abnormal BFI scores have shown that cognitive behavioral therapy of BFI can be used as an entry point. A study by Beck[9] found that being unloved and failing are common verbalizations of depression. Changing feelings will effect the thoughts, which in turn influence the outcome. Therefore, conclusions should to consider into culture environment. We further applied Wuxing to study depression in the context of the Chinese cultural environment.

In a previous study of high school students aged 16-19 years, depression scores were significantly higher in Chinese students than in American students, which may stem from different social and humanistic environments.[1] Ecology shapes culture, and culture influences the development of personality.[41] Culture can be viewed as an ecological assemblage system of personality traits.[42] Progress has been made in preventing relapse of depression through psychosocial treatment.[43] We chose to consider both social support and sense of hope in our study and found that self-beliefs and culture of the human environment were significantly correlated with depression. Therefore, human environmental interventions could potentially be used to treat depression in adolescents.[25]

Psychology studies the laws of occurrence, development, and change of psychological activities. Wuxing is guided by the basis of TCM theory to study the theory of transformation of human health and disease.

TCM psychology, also called Nature-Mind, which includes both, uses TCM principles to study and address psychological problems in the field of medicine and to assess the role of psychological factors in health and disease. The TCM mind quality includes innate spirituality, temperament, development of personality, ability, cognitive style, and other relatively stable traits and can instantly perceive and change the consciousness. The unique Chinese culture and other acquired environments have an effect on the personality and psychology of adolescents [Figure 3, arrow means Qi].

Figure 3.

Relationship between Wuxing and Qi

The prevalence of major depression increases significantly throughout adolescence, with a significantly greater increase in girls than in boys.[23] According to the Qi theory of traditional Chinese understanding of life, the occurrence of disease is related to varying degrees of Qi stagnation, and Qi stagnation of the internal organs has many different manifestations. Depression is the main clinical manifestation of a class of diseases, historically known as “emotional depression,” “due to the disease and depression,” and “due to depression and illness.”[44] According to TCM, the early stage of depression is dominated by Qi stagnation, and if the Qi is restrained, this leads to Qi stagnation, which can lead to phlegm-dampness internal obstruction, and disruption of blood flow, and can be further transformed into the hot and fiery symptoms. If liver Qi stagnation is the basis of the lesion, the condition tends to be chronic, and the change of the real to the virtual is seen as a deficiency in the Qi and blood, Yin-Yang of the organs. Early symptoms of Liver depression and Qi stagnation, can transform into internal heat, liver depression and spleen deficiency, phlegm and Qi stagnation, which can eventually lead to heart, spleen, and kidney deficiency and liver depression.[21,44] Although depression is a disease of the emotions and spirit, it may be related to the deficiency of the body’s Qi and a weakness in the flow of Tree in the liver and gallbladder.[20] Yin-Yang refers to the two opposing aspects of things, and the doctrine of Yin-Yang mainly explains the relationship of interdependence, mutual elimination, and mutual transformation between the opposing sides of things, whereas the doctrine of the Wuxing uses the Wuxing to categorize the attributes of things and the interrelationships between things.[45] Yin-Yang distinguishes the nature of Qi, and Wuxing distinguishes the flow or state of Qi.[20] Under the metaphorical cognitive perspective, the focus of the study of the doctrine of hiding is to reveal the mechanism of constructing the metaphor of TCM’s hiding concepts, so as to clearly recognize that TCM’s hiding concepts are verifiable at those levels.[46] The TCM theory of the Wuxing is based on the triad of “Qi – Yin-Yang – Wuxing,” which, as the most basic thinking mode of TCM, is inseparable from traditional Chinese culture.[47,48] TCM has its own unique theoretical system in physiology, pathology, diagnosis, and treatment regimen, and the basic spirit of its theoretical system is linked to the doctrine of Yin-Yang and Wuxing.[22] According to the doctrine of Wuxing, birth, restraint, and various things are universally linked, coordinated, and balanced by basic laws. It is used in TCM to explain the unity of the human body and its external environment, and to elucidate life, health, and disease from a systemic point of view.[49] The Wuxing organ system starts from the whole and analyzes the parts, as well as the relationship between the parts based on the whole.[48] In TCM, Wuxing theory focuses on the five organs, etiology, medicinal properties, and Qi. Its core content is Zangxiang theory, which focuses on the physiological functions and pathological changes of the five organs, which are manifested externally, and their interrelationships.[49] The understanding of the whole is achieved by analyzing its parts.[48] Wuxing theory can help with clinical diagnosis and choice of treatment. In depression, the movement of Qi between organs is out of balance. This has an effect on the body’s internal organs, meridians, Qi, and blood, leading to fluid stagnation and obstruction, resulting in symptoms of depression.[50] The Qi movements represent the cyclical changes of the energies of Wuxing, affecting the function of the human internal organs and emotional state.[51] Yin and Yang represent the relationship between things. If Yin and Yang are balanced, the spirit is normal, and the emotions are calm. When it is imbalanced, emotional abnormalities can occur.[50] In the set of relationships between male and female, the male is Yang and the female is Yin.[48] We studied gender separately based on the differences in the onset of depression, guided by the Yin-Yang theory. In Wuxing, the liver represents Tree, the heart represents Fire, the spleen represents Earth, the lung represents Metal, and the kidney represents Water.[22] Kidney, the “foundation of the innate nature,” is an important organ of the theory of source.[52] Kidneys store essence and are responsible for growth, development, and reproduction.[53] Gender characteristics appear in boys at puberty, so the kidney is taken as the source in males. From a TCM perspective, males and females are believed to have different qualities of Yin and Yang, just as the shape of essence and blood differs from that of Water. Most of them describe the changes related to reproduction during puberty from their perspective.[54] Thus, boys and girls are divided according to Yin and Yang, which corresponds with the kidneys and liver, respectively. “The woman is preceded by the liver” emphasizes the importance of the liver to female physiology.[55] Women take the liver as the base and take liver Qi as a precursor for excretion, and the psychological and physiological relationship of liver Qi is more closely related to women’s disease.[56] Adolescent girls began to experience the physiological cycle, embodied by the normal physiological function of menstruation, giving rise to the expression “Women to blood as the main effection to the liver for support.”[53] During menstruation, the hypothalamic–pituitary–gonadal axis is activated in adolescent girls, and multiple physiological and psychological changes occur, triggering disturbances in physiological development, social adaptation, emotional and affective problems, and peer interaction problems, which stimulate depression-related factors in adolescent girls.[56] Liver blood relies on the nourishment of kidney essence. Kidney essence is also constantly supplemented by the essence generated by liver blood to be sufficient and inexhaustible, so it is also known as “Essence and blood of the same origin.”[53] The liver is the main reservoir of blood; therefore, women’s physiology and pathology are related to the liver.[56] In the process of diagnosis and treatment, in addition to considering the depressed patient’s situation, their environment, the physiological stage, and psychological state should also be considered.

Our results showed that the higher the Wuxing scores of Tree in boys and Fire in girls, the lower the level of depression. According to Wuxing theory, interventions need to be analyzed from the perspective of transportation[22]: The Tree attribute refers to the Yang energy that emerges and grows like the trees in spring, keeping the mood comfortable and thriving, and does not strike or damage. The circulation of the Wuxing, as shown in Figure 3, transforms and constrains the other elements. The principle of the Wuxing circulation can be used to guide interventions by transforming the elements into a relatively stable and balanced state. Boys should be directed toward Tree so that they develop the quality of thriving, whereas girls should be directed toward Fire to encourage them to express and vent their emotions.

By applying the Wuxing theory of TCM and combining it with the pathogenesis of depression, we analyzed the innate factors based on the date of birth (DOB) and the influence of acquired environmental factors on these innate factors to examine the correlation between the onset and severity of depression. The results showed that different innate Wuxing and Qi endowments are associated with significant differences in the occurrence of depression. This suggests that different Qi endowments may be associated with different personality traits, which may be related to the typology of depression. This requires further investigation. We analyzed the degree of depression and Wuxing separately for boys and girls and found that Tree was negatively correlated with the degree of depression in boys, whereas Fire was negatively correlated with the degree of depression in girls. Males take the kidney as the heaven; the kidney represents Water, and Water nourishes Tree. Tree can effectively channel the surplus of the innate Wuxing endowment of males to keep the balance. Likewise, Fire can effectively channel the surplus innate elements of women, so that they tend to be balanced.

Limitation and recommendation

Our research subjects are high school students in China, and the sample has certain group and regional limitations. These findings need to be verified in a larger sample.

Chinese students spend most of their high school years studying in school for college entrance exams. The students’ mental health especially the occurrence of depression accounted for. Personality research has been widely applied, and there are also studies on the correlation between personality and depression.

We also want to intervene in the development of depression by studying personality or cultural factors. This study focuses on the Wuxing in traditional Chinese culture, applying the characteristics of the individual’s dominant Wuxing to intervene in the occurrence and development of depression.

We recommend the use of Wuxing for grouping intervention of depressed students, which has a positive effect on the prevention and retardation of depression.

Conclusion

Depression in adolescents is preventable and requires research and intervention.[57,58] In this study, we used a cross-sectional survey to study the relationship between personality and depression and extended the analysis with the application of Wuxing of TCM. Our findings suggest that the personality attributes of Neuroticism and Agreeableness have opposite effects on depression, increasing and decreasing the risk of depression, respectively. Wuxing can be used to understand the personality traits of participants from a broader perspective, and applying the results of the dynamics of Wuxing and Qi movement provides a deeper and more holistic view that encompasses nature and the environment (Qi movement). The interactions between social support, hope, personality, and Wuxing of TCM on adolescent depression explored in this study provide ideas for early diagnosis of depression and potential interventions. Taking into consideration the stage of adolescent psychophysiological development combined with the perspective of psychology and TCM, these results can be used to inform the prevention and treatment of depression, promotion of healthy growth, reduction of psychological problems, and improvement of translational science for depression diagnosis and treatment in adolescents.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Project supported by Basic Scientific Research Project Foundation of Beijing University of Chinese Medicine (2024-JYB-PY-021).