Depression is commonly observed alongside SUDs, demonstrating formidable obstacles to recovery and sustained abstinence (6). Neuroscientific research has uncovered neurobiological similarities in brain structure and function between SUDs and depression, suggesting shared pathophysiological underpinnings (7, 8). Epidemiological studies further highlight a robust association between SUDs and mental health disorders. Individuals suffering from severe depression are nearly twice as likely to develop SUDs as the general population (9, 10). Additionally, SUDs diagnoses are associated with a three to fourfold escalation in depression rates (11), a consistent pattern across substances like nicotine, alcohol, cannabis, opioids, and psychostimulants (9, 10, 12). A recent longitudinal study over 2 years involving 3,320 college-aged females found a significant association between alcohol and cannabis use and increased depression scores (13). The self-medication hypothesis suggests that individuals may resort to substances to mitigate negative emotions, such as depression and anxiety, potentially leading to substance dependence (14). Evidently, the severity of depression in individuals with SUDs correlates positively with their likelihood of relapse.

Self-esteem, integral to psychological capital and self-concept, is an individual’s consistent self-evaluation of worth, evident in levels of self-acceptance or rejection. Shahar and Davidson (15) argue that depression, a significant stressor, can erode self-concept and reduce self-esteem. Empirical evidence from longitudinal studies confirms this, showing that depressive states lead to declines in self-esteem among adolescents and university students (16, 17). Furthermore, using the experience sampling method, researchers assessed momentary self-esteem levels in individuals with clinical major depression and healthy controls. This assessment, conducted at 10 intervals daily over 6 days, revealed a pronounced double inverted U-shaped pattern of self-esteem in the depressed group, significantly lower than that of the controls, highlighting the profound impact of depression on self-esteem (18). Mruk (19) underscores the importance of self-esteem as a buffer against stress, vital for overcoming challenges in drug rehabilitation, such as withdrawal symptoms and relapse risk. This relationship is supported by a negative correlation between self-esteem and drug cravings, and a positive correlation with rehabilitation success (20). Further research indicates that low self-esteem may drive individuals toward substance use as a way to manage emotions (21, 22). Consequently, this research proposes Hypothesis 1 (H1): Self-esteem mediates the relationship between depressive mood and the propensity for relapse in individuals with SUDs.

Psychological resilience, an adaptive process, capacity, or characteristic, equips individuals to navigate through adversities, traumas, and significant stressors effectively (23, 24). Depressive individuals often exhibit diminished reactivity to both positive and negative emotions, leading to rigid coping strategies for stress and negative affect. This rigidity typically results in lower levels of psychological resilience (25). Vesco et al. (26) similarly identified the detrimental effects of negative thinking patterns on psychological resilience. Resilience not only facilitates emotional regulation and tolerance of negative emotions but also acts as a deterrent against the development of substance dependence (27). A cross-sectional study indicates that higher resilience levels correlate with decreased tendencies toward smoking, nicotine, alcohol consumption, and substance use (28). Therefore, this study hypothesizes (H2) that psychological resilience mediates the impact of depressive emotions on relapse in individuals with SUDs.

Self-esteem and resilience, as intertwined psychological protective factors, play an essential role in mitigating anxiety and depression amid setbacks and challenges (29). Connell et al. (30) propose that a positive self-concept is crucial for the development of psychological resilience. Research by Masten and her team further supports this, identifying positive self-evaluations such as self-confidence, high self-esteem, and self-efficacy as key characteristics that foster resilience (31). Particularly, high self-esteem boosts confidence in one’s abilities and promotes proactive strategies, thereby enhancing resilience. This relationship is underscored by a meta-analysis which reported a significant correlation (r = 0.55) between self-esteem and resilience (32). Moreover, research has shown that self-esteem and resilience sequentially mediate adaptability in the face of adversity (33). Therefore, these findings collectively suggest that self-esteem not only influences resilience but also plays a critical role in individuals’ ability to adapt and recover, leading to hypothesis 3 (H3) that in individuals with SUDs, depression impacts relapse through the chain-mediated effects of self-esteem and resilience.

Interventions aimed at depression, which effectively mitigate substance use, are associated with improved symptoms, reduced relapse rates, and enhanced recovery outcomes (34). Current treatments, including pharmacotherapy, cognitive-behavioral therapy (CBT), and psychotherapy, have shown efficacy in managing depressive symptoms in individuals with SUDs. However, these approaches are not without their limitations. For example, pharmacotherapy often faces challenges such as high costs and the potential for dependency, while CBT and psychotherapy may suffer from low patient adherence and inadequate evaluation techniques (35). In contrast, physical exercise not only addresses these limitations but also reverses physiological and neural damage caused by substance abuse and increases the release of brain-derived neurotrophic factor (BDNF), contributing to its antidepressant effects (36). Furthermore, research including a systematic review and meta-analysis has suggested that Qigong practice may alleviate depressive symptoms in individuals with SUDs, though the limited number and low methodological quality of these studies necessitate cautious interpretation (37). Consequently, further high-quality randomized controlled trials are needed to confirm these findings. Notably, previous investigations into the mental health benefits of Qigong have often overlooked the significant role of body posture, which may influence its therapeutic effectiveness.

The embodied cognition theory posits a fundamental and essential connection between cognitive processes and the physical body, suggesting that cognition is derived from bodily experiences and interactions. According to this perspective, cognitive functions and thought patterns are shaped by various factors, including anatomical structures, movement dynamics, sensory feedback, and the experiential qualities of movement (38). Recognizing the interconnectedness of physical and mental health, it can be inferred that altering bodily movements can significantly enhance psychological well-being and contribute to the management of various mental disorders, such as depression, insomnia, and autism (39). Darwin’s observations highlighted that slumped, relaxed, and downward postures are indicative of depression and sadness, whereas erect, upright, and open postures correlate with positive emotions (40). These emotional manifestations are evident not only in static postures but also in dynamic movements, such as walking patterns. Michalak et al. (41) found significant differences in the gait of individuals with severe depression compared to healthy individuals, with the former showing slower walking speeds, diminished arm swings, decreased vertical head motions, and more slouched postures. Furthermore, individuals experiencing depression displayed shorter stride lengths and increased stride durations relative to the healthy control group (42). Health Qigong, characterized by its static and dynamic body postures, represents a unique aspect of physical exercise (43). Static Qigong entails such as sitting meditation or stationary poses, focusing on breath control, body relaxation, concentrated attention, and the integration of mind and body to achieve physical health, increased internal energy, and mental serenity. Dynamic Qigong, conversely, emphasizes active bodily adjustments, breath guidance, and the application of principles to improve flexibility and strength, thereby promoting the efficient flow of qi and blood.

The embodied cognition theory emphasizes the interplay between mood and physical movement, suggesting that adjustments in body posture and movement can influence emotional states. Depression often presents with physical symptoms such as slowed movement, slumped posture, muscle tension, and pain (44, 45). To tackle these physical manifestations of depression, we meticulously curated Health Qigong exercises from traditional Chinese practices known for improving posture and promoting chest expansion. These include Baduanjin, Five Animal Exercises, 12-form Daoyin Health Exercises, and Mawangdui Daoyin. We developed a comprehensive anti-depression exercise regimen that features a sequence of movements such as the ready form, Holding Sky with Hands, Shuangyu Xuange, Longdeng, Tiger Pounce, Rouji Style, Deer Running, Golden Rooster Dawn, Bird Flying, Returning Qi to the Source, and the concluding form. Comprehensive descriptions of each action within the program can be found in Supplementary Table S1. Therefore, hypothesis 4 (H4) postulates that sustained engagement in Health Qigong not only diminishes depression among individuals with SUDs but also boosts self-esteem and resilience, and lower the risk of relapse.

Despite extensive research into the comorbidity of depression and SUDs and their relapse, significant gaps remain. Although the link between depression and SUDs relapse is acknowledged, the mechanisms underlying their interaction are still unclear. Additionally, while physical activity interventions have shown potential to alleviate depression symptoms, studies that target depression to subsequently reduce substance use relapse are scarce and often methodologically weak. Addressing these research needs, our study began with a cross-sectional analysis exploring the relationship between depression and SUDs relapse, with a focus on the potential mediating roles of self-esteem and psychological resilience. Following this, we conducted a pilot randomized controlled trial (RCT) grounded in embodied cognition theory. This trial utilized Health Qigong interventions aimed specifically at the physical manifestations of depression, assessing their effectiveness in improving depressive symptoms, enhancing self-esteem and psychological resilience, and reducing relapse risk. These two studies collectively aim to provide new empirical insights into the factors influencing SUDs relapse and their treatment, thereby establishing a scientific basis for developing innovative psychosocial intervention strategies.

This study aims to explore the relationship between depression and relapse in patients with SUDs, and to further examine the roles of self-esteem and psychological resilience as both individual and sequential mediators in this relationship.

This study investigates whether a 12-week Health Qigong intervention, aimed at alleviating the physical manifestations of depression, can reduce depressive symptoms in individuals with SUDs. Additionally, it examines whether this intervention can enhance self-esteem and psychological resilience, and subsequently lower the likelihood of relapse.

This study confirms a noteworthy positive correlation between depressive mood and propensity for relapse in individuals with SUDs. Depressive mood correlates with neurotransmitter dysregulation, including serotonin and dopamine, which are crucial to the brain’s reward pathway and implicated in drug addiction. Such dysregulation may impair neurotransmitter system functioning, consequently increasing relapse risk (49). Furthermore, depressive mood can also precipitate social withdrawal and less engagement in social activities, resulting in reduced access to essential social support networks. Given the critical role of social support in preventing relapse, insufficient social support amplifies vulnerability to relapse triggers (50). In summary, the effective identification and remediation of depressive symptoms can significantly lower relapse risk, accordingly enhancing treatment outcomes and promoting long-term recovery.

This study further explored how depression contributed to relapse, shedding light on the potential mediating role of self-esteem, thereby supporting H1. Notably, a significant negative correlation emerged between depression and self-esteem among individuals SUDs. Baker’s cognitive triad model of depression suggests that individuals experiencing depression are often prone to negative thinking patterns, including distorted self-perception, pessimism about the environment, and anticipation of negative outcomes. These patterns contribute to a detrimental cognitive cycle that diminishes self-esteem (51). Furthermore, the research demonstrated an inverse relationship between self-esteem and relapse risk in individuals with SUDs. Self-esteem is closely linked to self-efficacy, the belief in one’s ability to execute tasks and reach goals. Bandura highlighted that self-efficacy influences decision-making, goal setting, exertion of effort, perseverance through challenges, and stress management strategies (52). Individuals harboring diminished self-efficacy are predisposed to doubt their capacity to avoid temptations and sustain sobriety, thereby increasing susceptibility to relapse. They often view themselves as lacking efficacious methods for navigating life’s stressors and emotional difficulties, thus more frequently resorting to substance use as a coping mechanism. Enhancing self-efficacy has proven to be a viable preventive measure against relapse, thereby offering empirical support for the connection between self-esteem and relapse risk (53).

This study supports Hypothesis 2 by demonstrating that psychological resilience mediates the relationship between depression and the tendency to relapse. When confronted with stressful circumstances, depressive individuals tend to succumb to negative and repetitive thought patterns. This, in turn, adversely impacts their behavior and coping mechanisms, consequently diminishing their psychological resilience. Moreover, Pfau and Russo emphasized that resilience results from the integrated operation of various biological systems, such as the neuroendocrine, immune, and central nervous systems. Depression has the potential to compromise these systems, thereby reducing an individual’s resilience and their capacity to manage depression effectively (54). Furthermore, the research elaborates a significant correlation between increasing resilience among individuals with SUDs and a reduced likelihood of relapse. The Elaboration Likelihood Model elucidates the relationship between mental resilience and relapse by distinguishing two cognitive pathways in decision-making: the central and peripheral routes. The central route is engaged through meticulous evaluation, utilized when an individual exhibits high motivation and cognitive capacity. In contrast, the peripheral route, which depends on cognitive shortcuts, is triggered by low motivation or capacity (55). During depressive episodes, individuals grappling with drug dependence may default to the peripheral route, thereby heightening the risk of relapse. Conversely, individuals with substantial psychological resilience prefer the central route, employing profound reflection and efficacious coping strategies to avert behavioral disorders and foster better adjustment (56, 57). These findings indicate the pivotal role of psychological resilience both in bolstering the decision-making process and mitigating the risk of relapse.

The present study also revealed that the relationship between depression and relapse of individuals with SUDs can be mediated sequentially by self-esteem and resilience, thereby lending support to H3. High self-esteem predisposes individuals to interpret life events positively, which helps sustain an optimistic outlook in the face of adversity. This positive cognitive assessment is critical for the adoption of efficacious coping strategies, subsequently strengthening psychological resilience. Research by Mäkikangas et al. (58) highlighted optimism and self-esteem as fundamental and enduring components of resilience over time, underscoring their importance in bolstering mental resilience. Shu et al. (59) further accentuate self-esteem as an indispensable internal determinant for developing psychological resilience, vital for enhancing adaptability and reducing vulnerability. Consequently, depression undermines resilience through the erosion of self-esteem, thereby increasing the likelihood of relapse.

Embodied cognition underscores the physical basis of cognitive processes, arguing that abstract mental representations are anchored in bodily movements and sensory experiences (60). Within this theoretical framework, George Lakoff and Mark Johnson’s conceptual metaphor theory suggests that metaphors are a core cognitive tool, enabling individuals to understand the world by relating intangible concepts to tangible, directly perceivable ones (61). This theory illustrates those abstract notions, such as time, are comprehended through metaphorical connections to more concrete domains, such as space (62). Research indicates that expansive postures can boost creativity by fostering cognitive flexibility and transforming thought processes. In contrast, contractile postures are beneficial for tasks requiring definitive answers or solutions (63). Additionally, societal gender roles are conceptualized and categorized through metaphors of “soft” and “hard.” This metaphorical thinking activates brain memory’s modal information related to proprioception, hence influencing perceptions of softness and hardness, even in unrelated objects like sofas, showcasing the embodied impact on cognitive judgments (64).

Building on this foundation, the study developed a Health Qigong intervention specifically designed for depressive symptoms. It features upward stretching and expanding movements, contrasting with the typical physical manifestations of depression. Surveys conducted before and after the intervention revealed that regular participation in this program significantly reduced depressive symptoms, enhanced self-esteem, improved psychological resilience, and lowered the risk of relapse. These findings provide preliminary, yet indirect support for the embodied cognition theory, which posits that physical exercise profoundly influences cognitive functions and, in turn, modulates thought processes, judgments, attitudes, and emotional states (65). Further validation of these outcomes requires more direct and objective testing methods.

Although this study systematically investigated the determinants and mechanisms of relapse among individuals with SUDs and developed effective relapse prevention strategies, it is subject to several limitations. First, the sample representativeness was limited to male SUD individuals from Guangxi, China, which may affect the generalizability of the results. Future research should expand the sample to include participants of different genders, ages, cultural backgrounds, and geographical locations to enhance the external validity of the findings. Second, the study was limited to an immediate evaluation following a 12-week intervention period, which may hinder our understanding of the long-term effects and durability of the intervention’s impact. Future research should incorporate extended follow-up assessments to thoroughly examine the sustained effects of Health Qigong on relapse rates in individuals with SUDs. Third, all measures in the study were based on questionnaires, which are susceptible to personal bias. Incorporating physiological and/or behavioral measures could enhance the objectivity and reliability of the findings. Fourth, due to practical constraints, we could not employ advanced motion capture equipment and specialized emotional assessment tools. This limitation hindered our capacity to evaluate changes in body posture and the relationship between participants’ emotional states and their physical postures. As a result, our ability to fully explore the impact of Health Qigong intervention on embodied cognition elements was compromised, affecting the comprehensive validation of embodied cognition theory. Future research should use more sophisticated technologies in less restrictive settings to further validate and expand our theoretical hypotheses.