Mood Disorders in TCM, Focus on Depression - Part One
by Tony Reid
This article aims to clarify the often confusing situation that exists in both contemporary TCM and Western psychiatry regarding the group of related disorders labeled as ‘Depression’. Some of the more important misunderstandings are traced to their source and alternative viewpoints are presented that may lead to more positive clinical outcomes.
Depression in western medicine
It seems as if we are in the midst of a depression epidemic, which has been accompanied by a dramatic increase in the number of prescriptions for the SSRI class of antidepressant drugs over the last two decades. Without denying the reality of the extreme suffering experienced by a person with Major Depression, it would seem that in many instances the diagnosis of depression may not, in fact, be a valid one.
The generally accepted standard for psychiatric nosology is the Diagnostic & Statistical Manual of Mental Disorders IV - Text Revision, 2000 (DSM-IV-TR). According to the DSM-IV-TR there are five classes of depressive disorders:
● Dysthymic Disorder
● Depressive Disorder Not Otherwise Specified (NOS)
● Major Depressive Disorder (single episode or recurrent)
● Mood Disorder Due to a General Medical Condition with Depressive Features
● Substance Induced Mood disorders
The following discussion is concerned with the first three disorders.
1. Dysthymic Disorder
Dysthymic Disorder is characterized by the following clinical features:
a) Duration of at least 2 years in adults and 1 year in adolescents and children.
b) Depressed mood for most of the day, occurring more days than not, and accompanied by at least 2 of the following symptoms:
● Poor appetite or overeating
● Insomnia or hypersomnia
● Low energy or fatigue
● Low self-esteem
● Poor concentration
● Difficulty making decisions
● Feelings of hopelessness.
● Manic episodes must not have occurred, and Major Depression episodes must not have occurred in the first 2 years of the illness (1 year in children).
Dysthymic Disorder is a depressive mood disorder characterized by a chronic course and an insidious onset. Many people with Dysthymia report that they have been depressed all of their lives and have an outlook colored by a chronically depressed mood. The current consensus is that major Depressive Disorder, Dysthymia and Double Depression - a major depressive episode superimposed upon underlying Dysthymia - have the same biochemical origin. These depressive mood states share similar symptoms and respond to similar medications and psychotherapeutic approaches. By definition, Dysthymia is a chronic mood disorder, as distinct from Depressive Disorder Not Otherwise Specified (NOS).
2. Depressive Disorder Not Otherwise Specified (NOS) & Minor Depression
This class of depressive disorders generally refers to illnesses that fall outside of the two categories discussed above. The most clinically relevant is referred to as Minor Depression. This disorder may have features that are similar to Dysthymia but have not been present for the required time frame. Alternatively, it may share some of the features of Major Depression, but not the requisite five. The DSM-IV-TR includes a definition of Minor Depression as a research category but it is not a recognized diagnostic category. The clinical manifestations are two to five of the following signs and symptoms during the same 2-week period:
● Frequent depression as reported by the patient or by observers that causes significant distress and/or results in impaired functioning
● Loss of interest or pleasure in doing things
● Weight loss
● Trouble sleeping
● Lack of energy
● Psychomotor agitation or retardation
● Feelings of helplessness or worthlessness
● Trouble concentrating or making decisions
● Recurring thoughts of death and/or suicidal ideation
● The problems are not related to an existing or ongoing health or mental health issue
In comparison with Major Depression, patients with NOS may have fewer vegetative symptoms like poor appetite or diurnal mood variation, and more subjective symptoms such as self-blame, worry, irritability or lethargy. Minor Depressive Disorder is more prevalent in primary care than Major Depressive Disorder. Doctors are warned that failure to adequately treat this condition may have far-reaching impact on the health, functional status, quality of life, and cost of care for patients who suffer from it. The notion that Minor Depression requires minor treatment is misleading. Indeed, a patient with this disorder may have more severe symptoms and hence experience greater subjective suffering than a patient diagnosed with Major Depressive Disorder. Cognitive-behavioral modes of therapy and selective serotonin reuptake inhibitor antidepressants have demonstrated efficacy for primary care patients who have Minor Depression.
3. Major Depression
Major Depression is characterized by the following clinical features:
● At least 5 of the following signs and symptoms, during the same 2-week period, representing a change from previous functioning and must include either (a) or (b),
a) Depressed mood
b) Diminished interest or pleasure
c) Significant weight loss or gain
d) Insomnia or hypersomnia
e) Psychomotor agitation or retardation
f) Fatigue or loss of energy
g) Feelings of worthlessness
h) Diminished ability to think or concentrate, indecisiveness
i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide
● Symptoms do not meet the criteria for a mixed episode, i.e.criteria for both manic and depressive episode.
● Symptoms cause clinically significant distress or impairment of functioning.
● Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.
● Symptoms are not better accounted for by bereavement, i.e. the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
The causes of Major Depression include psychological, biological, and environmental factors. The current scientific opinion is that Major Depression is a biological, medical illness and the neurotransmitters norepinephrine, serotonin and dopamine are thought to be involved in its pathogenesis. Antidepressant medications work by increasing the availability of one or more of these neurotransmitters or by changing the sensitivity of neuron receptors to these substances.
There appears to be a genetic predisposition to Major Depression. Life events, such as the death of a loved one, a major loss or change, chronic stress, or alcohol and drug abuse, may trigger episodes of depression more easily in those with a familial history of Major Depression. Some illnesses such as heart disease and cancer and certain medications may also trigger depressive episodes. It is also important to note that a depressive episode may occur spontaneously, i.e. not triggered by a life crisis, physical illness, or other risks.
Limitations of the DSM-IV
The above discussion on Minor Depression points to some of the limitations of the DSM-IV and indeed, the DSM system has been the subject of considerable criticism. A summary of this criticism is as follows:
● It is descriptive and not based on etiology. The idea being that it would be useful for physicians with various ‘theoretical orientations’. Because it has a statistical and not an etiological basis, patients with the same diagnosis may not have the same etiology or require the same treatment.
● It emphasizes reliability over validity.
● It includes many disorders that are not psychological, e.g. impotence, premature ejaculation, jet lag, caffeine addiction, and bruxism (involuntary grinding or clenching of teeth).
● It has been overly influenced by the various multinational pharmaceutical companies, which have a financial interest in ‘widening the net’. In the words of one investigative journalist: ‘Every psychiatric expert involved in writing the standard diagnostic criteria for disorders such as depression and schizophrenia has had financial ties to drug companies that sell medications for these illnesses.’
The upshot of all of this is that the DSM-IV fosters a tendency to both over diagnose depression as well as to over prescribe the SSRI class of drugs (Metzl J.M. 2003; Shorter E. 1997).
The ‘Phasing Out’ of Neurasthenia
Perhaps one of the more insidious consequences of the hegemony of the DSM - IV is the dropping of term ‘Neurasthenia’, in favor of the label ‘Depressive’ and/or ‘Anxiety Disorders’. Neurasthenia as a disorder was first described in 1869 by the American neurologist G. M. Beard, as a disorder that arises when an individual’s commitments to work, family and relational/social needs over-tax the nervous system beyond its capacity to maintain normal functioning. Subsequently, Neurasthenia was commonly diagnosed in the USA and Europe. In China and Russia, it was the most common psychiatric diagnosis up until the 1980’s, until the impact of modern Western psychiatry and particularly the DSM-III, began to shape the academic and clinical landscapes. (Lee S. 1999) Cultural factors aside, it seems exceedingly strange that a disorder which was treated mainly by non drug methods, should be almost ubiquitously supplanted by disorders that are now treated primarily with pharmaceutical agents.
In practice many clinicians still make this diagnosis, basing treatment strategies on counseling, stress reduction, increased rest, nourishing diet and tonic herbal formulations. This is in keeping with the pathogenesis of exhaustion of the nervous system.
The clinical features of Neurasthenia comprise at least 3 symptoms:
● Weakness (mental or physical fatigue/decreased efficiency)
● Dysphoria (irritable, worrisome, inability to relax)
● Excitement - easily mentally excitable (accompanied by unpleasant feelings)
● Nervous muscular pain (e.g. tension headache, myalgia)
● Sleep disturbances
The disorder is of at least 3 months duration and there is a marked lowering of work, study or social functioning, which causes sufficient mental distress for the sufferer to seek treatment.
From the viewpoint of TCM, this is a valid clinical entity, which corresponds with various deficiency or xu (虚) type syndromes.
The Bio-psychiatry Model and the Influence of Multinational Pharmaceutical Companies
Since the 1980s’, research efforts have switched from the psychodynamic model to the biological model in which psychiatric disorders are treated chemically. ‘Bio-psychiatry’ is a term that has been coined to denote and promote the pharmaceutical industry’s preferred view of mental illness as a chemical imbalance. It has to a large extent replaced cognitive therapy as a form of psychiatric treatment and relies on the justification of evidence-based medicine. Obviously, research involving psychoactive drugs lends itself more readily to the ‘gold standard’ RCT model than the subtle and individual art of human skills based interventions.
In the 1950s’, pharmaceutical companies has little interest in developing antidepressant medicines because they could not see a market potential. Prior to the 1980s’, the prevalence of severe depression requiring hospitalization was exceedingly low and experts considered that depression was a psychiatric condition with one of the best prognosis - with or without treatment (Healy D. 2003).
During the 1980s’, multinational pharmaceutical companies, via their influence on the development of the DSM system and their own promotional activities, gave a different face to depression as an illness. The disorder came to be seen as a ‘chemical deficiency state’ that required the ingestion of SSRI drugs in order to return serotonin levels to normal. Due to the efforts of these companies to broaden the clinical applications of SSRI’s, what were once regarded as normal - albeit unpleasant - mental states have now come to be relabeled as depression or some other DSM-IV defined disorder.
The targets for these activities include not only psychiatrists, but significantly, family and general practitioners. The latter have literally been bombarded with exhortations to recognize the many depressed patients who would normally go undiagnosed. They are then supported with oversimplified diagnostic tests, including a screening questionnaire with only two questions and a four-point depression checklist.
In addition to exaggerating the risks of depression, the adverse effects of SSRI’s have simultaneously been minimized. This is achieved by selectively drawing on studies that support the efficacy of SSRI’s while repressing studies that highlight any adverse reactions. Indeed, pharmaceutical companies became involved in a concerted campaign to redefine the DSM-IV meaning of ‘prescription drug dependency’ so as to avoid the charge of addiction or withdrawal symptoms being associated with SSRI administration (Medawar C. 2004).
Selective Serotonin Reuptake Inhibitors
Selective serotonin reuptake inhibitors are marketed under the names Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox, Eflexor and Sarafem. The major differences between them are related to the individual side effect profile. According to the manufacturers’ product information, these drugs have approximately 240 different side effects. An American review of spontaneous adverse drug reactions found that over a ten year period, Prozac was associated with more hospitalizations, deaths or other serious adverse effects reported to the FDA than any other pharmaceutical drug in America (Moore T. 1998).
Spigset (Spigset O.1999) found that the following were the most common adverse events associated with SSRI use:
● Neurological - 22%
● Psychiatric - 19.5%
● Gastrointestinal - 18%
● Dermatological - 11.4%
In a study on the side effects of commonly prescribed antidepressants, it was found that 10% to 32% of patients taking Paxil, Zoloft and Eflexor experienced nervousness, agitation, tremor, dizziness, myoclonus, headaches or problems with sleep (Vanderkooy J.D. et al 2002). Some of these reactions, such as nausea, diarrhea, headache and agitation are transient and remit after the first 2 to 3 weeks but for a number of patients, these reactions are severe enough to cause them to discontinue treatment. This is significant because 2 to 6 weeks of a therapeutic dose level is required to observe a clinical response.
Some of the more significant long term side effects include:
● Increased risk of suicide, which is almost four times higher than for other forms of treatment.
● Increased risk of violent behavior
● Insomnia(15 - 20%)
● Weight gain (18 - 50%)
● Sexual dysfunction, generally decreased libido and delayed or absent orgasm
As mentioned above, the DSM-IV definition of prescription drug dependency was redefined under the influence of the multinational pharmaceutical companies to avoid the obligatory terms ‘dependence, addiction and withdrawal’ in connection with SSRI prescriptions. Research now indicates that 35% to 85% of people who abruptly stop taking an SSRI will develop one or more symptoms of withdrawal. These withdrawal symptoms include; a worsening of depression, insomnia, appetite changes, agitation and electric shock sensations. Because withdrawal symptoms can mimic the same symptoms the drug was initially prescribed for, this gives the appearance of a relapse - causing the prescribing of additional drugs or higher dosages of the original medication (Young A., Haddad P. 1997).
A study by Young and Currie found that 70% of physicians involved in a knowledge base survey said that they were unaware of antidepressant withdrawal events and only 17% said that they would caution patients about the possibility of such events (Young A.H., Currie A. 1997).
Although many studies tend to be biased and any negative results suppressed, SSRI’s are estimated to be clinically effective in 50% of cases. No doubt this figure is influenced by the number of patients who discontinue treatment because of the unpleasant reactions described above. Therefore, the only definitive statement that can be made at this point in time is that the efficacy of SSRI’s is modest and the burden and costs of harm are yet to be defined. (Healy D. 2003)
Perhaps the most telling drawback associated with the clinical application of SSRI’s is that over 80% of prescriptions are penned by general practitioners who have no specialized training in psychiatry or in the specific pharmacology of this class of drug.
Cohen eloquently describes the current situation: ‘The drug companies have vigorously marketed SSRI antidepressants not only to psychiatrists, who are supposed to have some expertise with these drugs, but also to general practitioners, pediatricians, gynecologists, internal medicine specialists, and anyone else who can prescribe. But this doesn't mean that they possess an in-depth knowledge of SSRI’s or their actions and toxicities. Many doctors don't know the difference between major and minor Dysthymic Depressions and that the latter responds better to much lower SSRI doses. Many doctors don't understand bipolar (manic-depressive) disorder and that high doses of an SSRI can trigger manic reactions. Even worse, many doctors think SSRI’s are the best treatment for anxiety symptoms. They aren't. Doctors should explain to patients that these drugs can initially worsen anxiety. If this happens, patients should contact their doctor and the dosage should be lowered. Do doctors actually warn patients about this? Rarely. Most doctors don't understand it themselves.’ (Cohen, JS. 2001)
Depression in TCM
Classical TCM literature contains references to various syndromes that are characterized by some of the signs and symptoms associated with depression. Although contemporary and pre-modern TCM texts give detailed analyses of the pathogenesis and treatment for the various syndromes that underlie the major presenting symptoms of depression - most typically sadness or melancholia - there is very little in depth discussion to correlate the differences between the various types of depressive disorders.
When modern Western psychiatry was introduced into China during the 1980s’ as part of Deng Xiaopings’ ‘open door’ policy, there was no equivalent entity in Chinese medicine corresponding to depressive disorders. With the introduction of the DSM-III into China soon after its’ publication in 1980, Chinese academic psychiatrists needed to find a word for depression or depressive disorder. Thus the term ‘yi yu zheng’ (抑郁证)was coined by borrowing the traditional pathogenetic term ‘yu’ and qualifying it with the term ‘yi’ meaning ‘suppress’.
In contemporary TCM, the term yu is reserved for stagnation of Qi that is associated with emotional strain and focuses specifically on Liver dysfunction. The alternative and relatively newer word, ‘zhi’ (滞), is used in reference to Qi when denoting stagnation or sluggish movement in a general sense – but without the implication of any emotional causes. In ancient and pre-modern times there was only one term for stagnation; the term yu.Yu was used to denote the stagnation, sluggish and restrained movement of Qi, Blood and Body Fluids in general. Thus, the contemporary usage of the term yu is often highlighted in translations by distinguishing it from the word zhi or stagnation. In clinical practice, syndromes characterized by yu may indeed give rise to the symptoms of depression but this is not always the case as there are many other syndromes that can manifest as depression. This difference was the subject of a recent study, which concluded, ‘The evidence supports the contention that stagnation oryu (郁) is a clinical syndrome distinct from depression’. (Siu-man Ng, et al. 2006)
There are several negatives that flow from the choice to translate the term yu as depression. Firstly, in discussions that occur within the medical context, the term yu could be mistranslated and taken to refer to psychiatric depression. In this way, Liver Qi depression or binding depression of Liver Qi may come to be regarded as the TCM equivalent of the Western medical term ‘depression’. This is simply not the case. These two TCM syndromes may be part of a differential diagnosis of a depressed mood but a diagnosis of ‘binding depression of Liver Qi’ for example, can include several other syndromes. I believe it would be better to drop the word depression from the English translations of TCM literature, rather than risk becoming an unwitting co-conspirator with the multinational pharmaceutical companies in widening their net!
Secondly, when translations are made from TCM Internal Medicine texts, discussions about emotion-related disorders fall under the heading of ‘yu zheng’ (郁证). This compound term qualifies the term ‘yu’ with the ideogram ‘zheng’ (证), meaning patterns or syndromes that denote the various types of disorders to be discussed. Conceptually, the compound term yu zheng is best translated as ‘emotional disorders’. It is incorrect to translate yu zheng as ‘melancholia’, ‘depression’ or ‘depression patterns/syndromes’ and discussions under the heading of yu zheng are not solely focused on DSM-IV Depression. These discussions are meant to provide an approach to the diagnosis and treatment of a limited number of disorders that manifest primarily with symptoms of emotional disorder. Depression is viewed as one such disorder, but the discussions also focus on disturbances such as uncontrollable anger, anxiety or hysteria.
Thirdly, some popular Western TCM authors apply this modernist approach to the translation of ancient and pre-modern works. As a result, historical texts that are concerned with elaborating the concept of stagnation are erroneously translated to give the impression that the author is talking about modern clinical depression. This mistranslation adds to the difficulties encountered by students and practitioners when searching through TCM literature for treatment approaches applicable to patients presenting with depressed mood.
Avoiding the stigmatizing influence of psychiatric nosology
It should come as no surprise to the astute reader that from this point on, I will no longer be referring to DSM-IV Depression or Depressive Disorder. I think that we do our patients and ourselves a disservice when we unquestioningly accept the diagnosis of depression. This is especially so if the patient did not receive this diagnosis from a qualified psychiatrist. Unfortunately, bio-psychiatry tends to perpetuate a ‘victim mentality’ in that the patient becomes convinced that his or her brain biochemistry has an enduring abnormality that can only be reversed by the ingestion of specific pharmaceuticals, usually on a long term basis.
One of the empowering aspects of TCM is that we avoid labeling our patients with an inflexible and seemingly permanent disease entity. While the philosophy of TCM permits a ‘here and now’ clinical assessment of a patient, it does so within the context of an ever-changing state of balance - both within the individual and between an individual and their environment. A patient may be experiencing a state of unexplained sadness, fatigue or lack of interest, but this is seen as a temporary manifestation of one or more specific types of imbalance within the patient. What these imbalances are, how we recognize them and how we approach treating them will be the subject of Part Two of this article.
Tony Reid has been actively involved in TCM, as a practitioner and educator, since 1980. He has lectured at the Zhejiang Academy of TCM and the Zhejiang College of TCM (both in Hangzhou, China) on the standardization of English nomenclature in TCM Tony is now director of Sun Herbal Pty. Ltd
First published in the NZRA Journal of TCM.
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