Chinese Medicine Times : Keeping You Informed

Chinese Medicine Times : Keeping You Informed

Depression: Towards an Integrated Approach - Part Two

by Tony Reid

Depression in Traditional Chinese Medicine

The Limitations of Contemporary TCM Literature

‘In the 20th Century, modern China rescued its traditional medicine from oblivion at the cost of removing it’s soul…’ (Maciocia, G. in Kaptchuk, 2000)

The chaos and destruction wreaked on all aspects of Chinese culture and civilization that marked the period known as the Cultural Revolution (1966 – 1976) extended to and included both psychiatry (then a nascent branch of Western medicine) and the psychiatric components of TCM. The new cultural taboo against personal emotions – particularly the expression of negative emotions like depression – were linked to severely degrading and socially debilitating punishments during this period (Flaws, 2004; Lee, 1999; Jung, 1991 pp. 362-480) The national standardization of TCM that occurred during this period resulted in the publication of textbooks that contain very little information on common psychological problems such as depression and anxiety; what little information they do contain is strongly imbued with a Marxist-materialism orientation. (Fruehauf, 2000). Indeed, while the emotions are briefly mentioned as potential factors in diseases causation, an in-depth analysis of human emotions is notably lacking. (Sivin, 1987, pp. 203-427; Chai, 1998) It would be reasonable to expect, for example, that under the then prevailing social conditions Chinese doctors would have something very significant to say regarding the diagnosis and treatment of post traumatic stress disorder. However, textbook TCM has surprisingly little discussion on such mental health problems, which would have been encountered on a daily basis. (Peng, 2000, pp. 345-355; Deng, 1999, pp.437-443). Moreover, on close examination one finds a certain amount of misinformation, some of which has, in turn, been transmitted and amplified by Western authors. This will be discussed in more detail below.

The classical literature of TCM contains reference to various syndromes that are characterized by some of the signs and symptoms associated with Depression. (Rossi, pp.125-165) However, there is really no one-to-one correlation between them and any of the various types of Depressive Disorders. Typical contemporary Chinese texts on Internal Medicine give detailed analyses of the pathogenesis and treatment strategies for the various syndromes that may underlie a major presenting symptom – in this case: ‘melancholia’, ‘neurosis’ or ‘emotional disorder’. (Peng, 2000, pp. 350-355; Hou, 1996, pp. 26-35; Shi, 2003, pp. 225-230) However, there is the potential for much of this information to be misleading because of nomenclature issues.

Nomenclature and Translation Issues

When modern Western psychiatry was introduced into China during the 1980’s (as part of Deng Xiao-ping’s ‘open door’ policy), there was no equivalent entity in Chinese medicine corresponding to clinical Depression. 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 yi yu zheng was coined by borrowing the traditional pathogenetic term yu, and qualifying it with yi 'suppress’. (Lee, 1999)

In contemporary TCM, the term yu is reserved for stagnation of the Qi that is associated with emotional strain and centers on Liver dysfunction. (Xie, 2003, p. 87) In most contexts this signifies a failure to give vent, marked by a sense of frustration (Bensky et al., 2006; Shi, 2006). The alternative, relatively newer term, zhi, is used in reference to the Qi to denote stagnation or sluggish movement in a general sense – without any implication of emotional causes. However, in ancient and pre-modern times there was only one term for stagnation: yu. This term was used to denote stagnation, sluggish or restrained movement (of the Qi, Blood or Body Fluids) in a general sense. (Xie, 2003, p.87) Thus, the contemporary usage of the term yu 郁is often highlighted in translations by distinguishing it from zhi ‘stagnation’ with the rendering of ‘constraint’ or ‘depression’. In clinical practice syndromes characterized by yu 郁 may indeed give rise to some of the symptoms of clinical Depression (i.e. depressed mood and loss of appetite); however, this is not always the case. In addition, there are several other TCM syndromes that may give also rise to the clinical features of Depression. This difference was the subject of a recent study, which concluded: ‘The evidence supports the contention that stagnation (i.e. yu) is a clinical syndrome distinct from Depression. (Siu-man Ng, et al. 2006) There are several negative consequences that flow from the choice to translate the term yu as ‘depression’. The first is that, in discussions which occur within a medical context, this will be taken to refer to modern psychiatric ‘Depression’. In this way ‘Liver Qi depression’ may come to be regarded as the equivalent of Depression. This is, in fact, may be misleading: such syndromes may be part of the differential diagnosis of ‘depressed mood’ but the latter also includes several other important syndrome-patterns.

The second consequence arises when translations are made of TCM Internal Medicine texts. Discussions about emotion-related disorders as a disease category fall under the heading of yu zheng. This compound word qualifies yu with the ideogram zheng ‘patterns’ or ‘syndromes’, which is commonly used in this context, denoting the various types of disorders to be discussed under this heading (including pathogenesis, differential diagnosis and treatments). Conceptually this compound is best rendered as ‘emotional disorders’. It is erroneous to translate this as ‘Melancholia’, ‘Depression’ or ‘Depression Patterns/Syndromes’. Discussions under this heading are not specifically concerned with DSM-IV Depressive Disorders; they are meant to provide an approach to the diagnosis and treatment of a limited number of disorders that manifest primarily with symptoms of emotional disturbance (including uncontrollable anger, anxiety and hysteria).

A third, and perhaps the most insidious, consequence is that some authors apply this ‘modern’ approach to the translation of ancient and pre-modern works. (e.g. Wiseman & Feng 1998) As a result, discussions that are in fact concerned with elaborating the concept of stagnation in TCM are rendered so as to give the false impression that the author is dealing with clinical Depression. (e.g. Yang, 1993, pp. 31-34, 451) This further compounds the difficulties encountered by students and practitioners alike when searching through the TCM literature for treatment approaches that may be applied to patients with depressed mood.

Emotions and Emotional Disorders in the Classical Literature

In modern transmissions of TCM theory the precise nature of the relationships between an individual’s psychic life and the Zang-fu organs are generally described with lists of correspondences between an organ and various emotions and mental faculties. This generally leads to the assumption that ‘fear comes from the Kidney’; ‘grief arises in the Lung’, etc. However, if we closely examine our classical sources we find that an important differentiation is made between the origins of our emotional responses and the pathological consequences of the same. According to the Ling Shu, Scroll 2, chapter 8: ‘When the Liver (Qi) is deficient, fear (or a ‘sense of absence ’-see end note 1) will occur; when excess, one will become angry. When the Heart (Qi) is deficient, sorrow will occur; when excess, unceasing laughter will occur - see end note 2.’ This is the only reference in the entire Nei Jing to emotions ‘coming from’ organs. Thus, according to the major classical source of Chinese medicine, only the Liver and Heart – more specifically, the shen and the hun residing in these organ systems – are capable of generating emotions. While various emotions can gravitate to different organs and cause damage to them, the psychic aspects of the Heart and Liver alone are the source of our emotional life – for better or worse. (Wu, 1993 pp.40-41; Yong, 2003)

When an emotional state is prolonged or intense, other organs tend to become involved. In chapter 5 of the Su Wen, the pathological consequences of emotional excesses are discussed:

• Anger injures the Liver
• Joy injures the Heart
• Worry and anxiety injure the Spleen
• Sadness injures the Lung
• Fear injures the Kidney
• Shock injures the Kidney and Heart
(Ni, 1995, pp.17-26; Yong, 2003)

Thus, the primary pathodynamic factors in psychological disorders involve the Heart and Liver organ systems. Therefore, in the diagnosis and treatment of depressed mood, we need to focus primarily on the Heart and the Liver, particularly in the early stages and in less severe presentations. However, in prolonged or severe conditions other organs may also become involved – principally the Spleen (Earth, damaged by worry and anxiety and ‘controlled’ by the Liver-Wood) and the Lung (Metal, injured by prolonged sadness and grief). In terms of primary (ben) and secondary aspects (biao), dysfunction of the Heart and/or Liver is primary, while the involvement of other organs, when present, is secondary.

At this point it is also pertinent to remind the reader that the original classics of TCM have a spiritual (as opposed to materialistic) orientation: the forces of the spirit (shen) and Qi dominate matter. Thus ‘If the spirit is at peace, the heart is in harmony; when the heart is in harmony, the body is whole ... if one seeks to heal the physical body, therefore, one needs to regulate the spirit first.’ (quote from the Baizi quanshu in Fruehauf, 2000) This is diametrically opposed to the orientation of Chinese medicine texts from contemporary China, which place material causes in the leading role. (Fruehauf, 2000; Sivin, 1987) However, while acknowledging the supremacy of the spirit, it is an undeniable fact that physical factors may profoundly influence our mental and emotional states - see end note 3.

In the traditional literature we find that the health of the spirit (shen) in the Heart depends upon the following:

• Moral ideals – clearly defined values
• Harmonious relationships with significant others
• Cultivation of harmony with nature
• Integrity
• Self cultivation: developing talents, skills and abilities to realize one’s potential (for the benefit of others – not for self aggrandizement)
• Self-control (in order to support the above values)
• Self reflection (to gain greater self knowledge in order to improve one’s relationships, work etc.)
(Dharmananda, undated; Kaptchuk, 2000, pp. 58-66, 157-159; Ni, 1995, pp.1-2; Wu, 1993, pp.40-41; Sivin, 1987, pp. 49-50, 96-99)

The above list provides us with the accumulated cultural wisdom of the Chinese in regard to achieving fulfilment in life as well as developing resilience to both external and internally generated stressors. It may be used as a guide in the global assessment of patients who experience difficulties in dealing with their sadness, as well as providing a foundation for long term ‘treatment’ (in the broadest possible sense of the word).

Patients with a clear diagnosis of clinical Depression – those who exhibit a pathological response to distressing circumstances (i.e. exaggerated response or continued response after the circumstances have been resolved), or in whom no cause can be found for the depressed mood – may be regarded as having a severe disturbance of the Heart-spirit. It is the author’s opinion that in this group of patients (who would unequivocally fall into the category of Major Depressive Disorder) the primary aim of therapy should be symptom relief; for it is only when the consciousness has become clearer that other forms of therapy may effectively be applied. This is in line with the commonly applied TCM treatment approach of treating the severe symptom manifestations (biao) first and the underlying causes (ben) later.

Depression According to Contemporary Western TCM Authors

For the reasons presented above, Depression is generally poorly presented in Western TCM literature. Flaws refers to the Western nosological categories of ‘melancholia’ and ‘characterologic depression’ in the chapter on ‘Frequent Sorrow’ as a traditional Chinese disease category (Flaws & Lake, 2001, p.121). The chapter devoted to Depression is clearly aimed at dealing with DSM Major Depression, in spite of his reference to ‘agitated’ and ‘vegetative’ types of depression. (Flaws & Lake, 2001, p.323) Typically, disorders of the Liver are described as fundamental to the pathogenesis and manifestation of Depression. (Flaws & Lake, 2001, p.327; Flaws, 2004) In addition, there is a lack of differentiation between primary cases and secondary, with the inclusion of various Kidney syndromes, Qi stagnation with Blood stasis, and ‘Phlegm-Qi Depression and Binding’. This work perpetuates some of the errors of the original Chinese texts, which included a variety of emotional disorders under the heading of ‘Depression’ or ‘Melancholia’ by including syndromes that are more closely underlie anxiety or hysteria than depression, e.g. Kidney Yin deficiency with Yang hyperactivity (anxiety disorders); Phlegm-Qi Depression and Binding (= plum pit qi = globus hystericus). The pattern analysis concludes with the author’s clinical tip: ‘the most common pattern of unipolar depression among Western patients is liver depression and spleen vacuity with depressive heat’. However, this is not backed up by any references to clinical research. Maciocia’s earlier work also reflects the orthodox TCM bias (Maciocia, 1994, pp.197-280) with recommendation of Yue Ju Wan (see end note 4) as the base formula in the treatment of depression. However, in a more recent publication he describes fourteen different patterns that may be associated with depressed mood, including all of those that appear in Chinese publications under the more general category of ‘Emotional Disorders’ (as discussed above). (Maciocia, 2004, pp. 797-798) Deng describes four patterns, only two of which are relevant. (Deng, 1999).

Perhaps the most reasonable and thorough discussion of Depression appears in Schnyer & Allen’s text, although it suffers from the same limitations as the above mentioned works, many of which were used as source material. (Schnyer et al., 2001). For instance, in the exposition on the Kidney a clear distinction is made between the psyche (shen) that is housed in the Heart and the essentially physical nature of the essence (jing) that is housed in the Kidney: ‘Shen refers to the organizing force of the self, whereas jing refers to the material substance;…’ (Schnyer et al., 2001, p.45). However, although stating that the Liver, Heart and Spleen are ‘the most important viscera associated with the mechanism of depression’ (Schnyer et al., 2001, p.48) and that they ‘seem to be involved most directly with the core symptoms of major depression’ (Schnyer et al., 2001, p.62) they also state that the Kidney and Lung are involved in the ‘precipitation of depressive episodes’ (Schnyer et al., 2001, p.48) However they do note the secondary role of other zang-fu, explaining that ‘the interactions of these (i.e. Liver, Heart and discussion on the evolution of the various pathodynamics in Depression, describing the development of secondary pathologies from primary disorders of the Liver, Heart and Spleen. (Schnyer et al., 2001, pp.67-77) Spleen) with other viscera and bowels can play a role in the appearance of other physical and psychological symptoms seen during depression’ (Schnyer et al., 2001, p.62)

The authors of this text present a very clear However, the clarity begins to become lost with the list of thirty two different individual patterns (classified under seven headings), described as ‘main basic patterns in major depression’. (Schnyer et al., 2001, pp.88-89) This is followed by a chart giving ‘The 12 Main Basic Patterns and Pattern Combinations’, which has the potential to further confuse rather than clarify the discussion. (Schnyer et al., 2001, pp.111)

The Pathogenesis of Depression in TCM – an exploratory analysis

Despite its many limitations, the author believes that the wu xing theory provides a useful framework for understanding both clinical Depression as well as depressed mood. Viewed in simple terms, Depression can best be defined by what is absent from the psyche of the depressed individual, compared with what is present in a normal healthy individual, namely:

1. A sense of joy
2. The ability to respond emotionally and express emotions
3. The ability to give significance or meaning to things

The first is related to Fire; the second to Wood; the third to Earth - see end note 5. Thus we have failure of function in these three aspects of the wu xing, implicating the involvement of Heart-Pericardium (see end note 6) , Liver and Spleen in the pathogenesis of Depression. In addition, as has been noted by Schnyer & Allen, the key signs and symptoms of clinical depression (according to DSM-IV and ICD-10) point directly towards Liver, Heart and Spleen pathologies. (Schnyer et al., 2001, p.62)

In light of the above discussion, the Heart and Liver disorders are primary, while Spleen deficiency is secondary (i.e. a person with Spleen deficiency alone will just feel tired; he will only experience depressed mood when the Liver and/or the Heart become involved)

The most empowering interpretation – both for the patient as well as the practitioner – of the pathogenesis of depression centres on a person’s innate ability, and responsibility, to actively engage in the maintenance of their own health, both physical and mental. Thus, the main contributing factors may be categorized as:

1. The experience of prolonged or intense emotional strain.
2. Lack of emotional self control.
3. Imbalance between work and leisure, i.e. too much of the former and not enough of the latter, particularly if work brings little personal satisfaction.
4. Excessive mental work, i.e. prolonged and intensive mental work without adequate rest or physical activity.
5. Lack of a clearly defined value system
6. Lack of harmonious interpersonal relationships
7. Failure to cultivate harmony with nature
8. Lack of personal integrity
9. Neglect of self cultivation (i.e. development of talents, skills and abilities to realize one’s potential and benefit others)
10. Poor self-control
11. Inadequate of self knowledge

Any one or a combination of the above may weaken the spirit and lead to the development of specific organ system imbalances, i.e. Liver Qi constraint, Heart Blood deficiency, and/or Spleen Qi deficiency. These, in turn, have a variety of pathological consequences:

• Liver Qi constraint may lead to one or more of the following: Spleen Qi deficiency, generalized Qi stagnation with loss of harmony between the internal organs, Blood stasis and Fire.
• Spleen Qi deficiency may lead to Blood deficiency, which will further affect the Heart. It may also lead to retention of Damp and the development of Phlegm, which may cloud the mind and senses.
• Qi stagnation may lead to food stagnation as well as the disruption of fluid metabolism, the latter also contributing to the development of Phlegm.
• Fire from stagnant Liver Qi can agitate the mind as well as deplete the Blood, leading to Blood deficiency (possibly also Yin deficiency).

These pathodynamics may be summarized under three categories, headed by the three major organs involved with depressed mood:

1. Liver Qi constraint / Liver Blood deficiency, with possibly the development of stagnant Heat, and/or Blood stasis
2. Heart deficiency (one or more of Qi, Blood, Yin) with possibly the development of deficiency Heat
3. Spleen Qi deficiency (with possibly the development of Damp, Phlegm or Stomach Qi/Yin deficiency)

For ease of clinical diagnosis and treatment, four major syndromes may be described for patients with depressed mood:

1. Liver Qi constraint
2. Instability of the Heart Qi
3. Heart-Blood and Spleen-Qi deficiency
4. Phlegm clouding the mind and senses

It should be noted that patients mostly present with combinations of the above. However, for simplicity and ease of presentation they are discussed separately. In addition, other pathodynamics may also be present and these need to be assessed on an individual basis, bearing in mind that the above syndrome patterns should remain the primary concerns in treatment.

Liver Qi Constriant

This syndrome is characterized by failure of the Liver to maintain the smooth and even flow of the Qi throughout the body, leading to stagnation of the Qi, particularly in the Liver organ and the Liver channel. In essence this syndrome is the manifestation of disharmony between the Liver Qi and the Liver Blood, in that the Liver Blood fails to temper and moderate the Liver Qi. Thus, Liver function (i.e. the Liver Qi) becomes inhibited leading to what is essentially a deficiency type syndrome. This manifests in a diminution of emotional responses, i.e. depressed mood with loss of a relaxed and easy-going attitude, together with disturbances along the course of the Liver channel (chest, breasts and hypochondrium). In addition, there is generally also disruption of the middle Jiao (Stomach and Spleen) functions. The latter may occur through the restriction (ke) relationship between the Wood and Earth or, alternatively, because the Liver fails to regulate and promote the normal Qi movements of the middle Jiao.

Key clinical features

• Patient feels ‘stressed’, ‘wound-up’, ‘frustrated’, ‘irritable’
• Discomfort in the hypochondrium and/or chest (needs to make an effort to take a deep breath)
• Menstruation disorders (e.g. irregular cycle, PMT)
• Aggravation of physical symptoms by emotional strain
• Fatigue, dizziness (postural), loss of appetite
• Wiry pulse (usually also thready)

Treatment Principles

Soothe the Liver and resolve Qi stagnation (possibly also tonify the Spleen Qi and Liver Blood)

Acupuncture

Taicong LV 3, hegu LI 4, qimen LV 14, ganshu UB 18
With stagnant Heat: xingjian LV 2, quchi LI 11, fengchi GB 20, neiting ST 44

Herbal Formulas

Xiao yao san (Rambling Powder)
Chai hu shu gan wan (Bupleurum Powder to Dredge the Liver).
With stagnant Heat: jia wei xiao yao san (Augmented Rambling Powder)

Instability of the Heart Qi
This is also known as the ‘restless Zang-organ disorder’. It is a general deficiency of the Heart, including Heart Qi, Blood and Yin deficiency. It was first described by Zhang Zhong-jing (circa 150 – 219 CE) and recorded in the ‘Synopsis of Prescriptions of the Golden Cabinet’ (jin gui yao lue fang lun), under the heading of gynaecological disorders. However, this syndrome may occur in either sex. The overall treatment strategy for these patients should include not only tonifying the Heart and calming the mind, but also addressing associated pathogenic factors, such as Fire from stagnant Liver Qi, Spleen Qi deficiency, etc.

Key clinical features

• Uncontrollable, overwhelming emotional changes
• Restlessness
• Poor concentration
• Palpitations
• Poor sleep
• Possibly also anxiety
• Possibly also disorientation
• Thready pulse

Treatment Principles

Tonify the Heart Qi, nourish the Heart Blood and Yin, calm and stabilise the mind.

Acupuncture

Shenmen HT 7, neiguan PC 6, xinshu UB 15, shentang UB 44, jiuwei REN 15, juque REN 14, shanzhong REN 17, baihui DU 20, zusanli ST 36, sanyinjiao SP 6, guanyuan REN 4, Qihai REN 6

Herbal Formulas

Gan mai da zao wan (Licorice, Wheat and Jujube Decoction)
An shen ding zhi wan (Zizyphus with Polygala Decoction)

Heart Blood and Spleen Qi Deficiency

Because of the close relationship between the Heart and the Spleen in terms of Blood production as well as circulation, deficiency of the one may readily affect the other. Clinically, this is a commonly occurring dual syndrome that may arise due to inadequate care during the recovery phase of an illness, chronic blood loss, excessive worry, anxiety or mental work, dietary irregularities and overstrain. It may readily develop in students due to the added stresses of examinations as well as in athletes due to overtraining.

Key clinical features

• Patient complains that they can’t ‘switch off’ their mind, especially at night
• Insomnia
• Cognitive disturbance (poor memory and concentration)
• Palpitations
• Pallor, fatigue, poor appetite
• Pale tongue
• Thready-weak pulse

Treatment Principles

Tonify the Qi and strengthen the Spleen, nourish the Heart Blood and calm the mind

Acupuncture

Xinshu UB 15, geshu UB 17, pishu UB 20, shenmen HT 7, sanyinjiao SP 6, zusanli ST 36

Herbal Formulas

Gui pi tang (Restore the Spleen Decoction)
Ren shen yang rong tang (Ginseng Decoction to Nourish Luxuriance)

Phlegm Clouding the Mind and Senses

The idea is that the mind and senses are obstructed by Phlegm. This condition may arise as a sequel to Phlegm-Fire mental agitation (as seen in bipolar disorder) when the disorder has ‘run its course’ and left the patient in a deficient condition. Alternatively, it may arise due to Qi stagnation caused by emotional strain or over-stimulation (via Liver constraint). The Qi stagnation causes impediment to the fluid passages, thus generating Phlegm. This process may readily occur in cases with pre-existing Spleen Qi deficiency. The Phlegm is carried upward with the counterflowing Liver Qi to disrupt the mind and senses (i.e. the Heart) in the Upper Jiao. This syndrome is characterized by both substantial as well as insubstantial Phlegm.

Clinical Features

• Apathy, depressed mood, mental confusion, somnolence
• Excessive sputum or mucous
• Gurgling sound in throat (due to sputum or mucus)
• Tongue body is pale and may also be swollen, with a white, greasy coat
• Pulse is slippery

Treatment Principles

Resolve Phlegm to open the mind and senses.

Acupuncture

Fenglong ST 40, jianshi PC 5

Herbal Formulas

Er chen wan (Two Aged Decoction)
Wen dan tang (Warm Gallbladder Decoction)
An shen ding zhi wan (Zizyphus with Polygala Decoction)

Acupuncture points for general use in depression

Sishencong (M-HN-1), yintang (M-HN-3), baihui DU 20, anmian (N-HN-54), neiguan PC 6, renzhong DU 26

Research and Clinical Outcomes

A 2004 review of clinical studies concluded that ‘there is insufficient evidence to determine the efficacy of acupuncture compared to medication, or to wait list control or sham acupuncture, in the management of depression. Scientific study design was poor and the number of people studied was small.’ However, the authors noted, rather promisingly, that ‘there was no evidence that medication was better than acupuncture in reducing the severity of depression, or in improving depression, defined as remission versus no remission. (Smith &Hay, 2004) A 2007 systematic review of randomized controlled trials of acupuncture in the treatment of depression concluded that ‘Despite the findings that the odds ratios of existing literature suggest a role for acupuncture in the treatment of depression, the evidence thus far is inconclusive.’(Leo & Ligot, 2007) A recent randomized controlled trial to assess the efficacy of acupuncture as an intervention for patients with DSM-IV Major Depressive Disorder (MDD), involving 151 subjects, concluded that ‘results fail to support its efficacy as a monotherapy for MDD.’ (Allen et al., 2006)

Both animal and human studies have shown that acupuncture is able to modulate central monoamine neurotransmitters, which may be the key to its effect on mood regulation. (Xu et al., 2007; Zhou & Wu, 2007; Cabyoglu et al, 2006; Pohl & Nordin, 2002).

One of the limitations of many trials and reviews is the failure to differentiate clinical Depression from minor or mild depression (i.e. cases in which the patient, although presenting with a depressed mood, does not fulfill the criteria, discussed above, of a real clinical psychiatric disorder). Chinese studies, in particular, are susceptible to both poorly defined criteria for Depression as well as poor trial design. For instance, it is possible to selectively place patients with mild/minor depression and associated Liver Qi stagnation into the TCM treatment group, placing those with clinical Depression and more complex TCM syndrome-patterns into the comparison and placebo groups. In this instance it would be very surprising if the TCM group did not show a significant response to the acupuncture treatments! However, there is no doubt that such studies do show that acupuncture may be an effective treatment for patients with depressed mood (but not necessarily with clinical Depression), comparable with the tricyclics and the SSRI’s. (e.g. Liu & Li, 2007; Du et al., 2005; Wang, 2005; Han et al, 2004; Han et al., 2002; Luo et al., 1998) The same criticisms and potential positives also apply to Chinese studies on the efficacy of various herbal formulations in the treatment of Depression. (Luo, Qian, Zhao, Bi, Xin, Jiang et al., 2006; Shen et al., 2004) In addition, various animal studies have demonstrated the neurophysiologic actions of herbal treatments, some showing similar efficacy to antidepressant drugs (for selected parameters), e.g. the classic formula Ban Xia Huo Po Tang (Pinellia and Magnolia Bark Decoction) has been the subject of several such studies (Wang et al., 2005; Zhang et al., 2004; Guo et al., 2004; Luo et al., 2000)

Assessing the Evidence

The absence of credible, unambiguous and high quality evidence for both TCM and Western approaches to treatment presents a major obstacle to any meaningful comparisons. Based on the material discussed above, I would propose that patients with a clear diagnosis of clinical Depression should receive antidepressant medication, administered under the guidance of a qualified psychiatrist. In an ideal world, other therapeutic modalities would provide a supporting role, e.g. cognitive psychotherapy (mindfulness-based), adoption of a healthy lifestyle (with attention to nutrient status, diet, exercise and relaxation/stress management) together with TCM treatments. The initial aims of this combined approach would be improvement of mood (with antidepressant medication), detection and correction of contributing factors (through psychotherapy, counselling, nutrition, physical fitness, stress management, etc.) and balancing the physiology (with acupuncture and Chinese herbal medicine). The early goals of such an approach would be to discontinue the medication as soon as possible, while shifting the responsibility to the patient for implementing and maintaining healthy lifestyle practices. TCM treatments would continue until physiological balance has been established.

On the other hand, patients who are not suffering from clinical depression (i.e. Depression NOS, Minor Depression, Mild or Moderate Depression – those patients in the depressed mood ‘with cause’ category) should only receive medications as a last resort. The risk to benefit ratio does not appear to justify the indiscriminate use of antidepressant drugs. There are encouraging signs that herbal medicines, acupuncture, nutrition, mindfulness-based cognitive therapy and other health-promoting lifestyle factors – administered under the guidance of a skilled and compassionate practitioner – may be all that is needed to produce a successful outcome in these cases.

Biography

Tony Reid (MTCM, DTCM, DAc) has been actively involved in Chinese medicine as practitioner, educator, lecturer and author since 1980. Receiving the bulk of his training in Australia, he has also studied and trained in Hangzhou (PRC), where he has contributed to the development of standardized English nomenclature for the interpreters at the Zhejiang TCM Academy and the Zhejiang College of TCM. In recent years, he has authored two clinical reference manuals on prepared Chinese herbal medicines, ‘Essential Formulas’ and ‘Empirical Formulas’. He is a contributor to professional journals such as ‘The Natural Therapist’, ‘NZRA Journal of TCM’, ‘The Lantern’, ‘Australian Journal of Acupuncture and Chinese Medicine’, ‘The Journal of Chinese Medicine’ and ‘Chinese Medicine Times’. Tony conducts annual seminars and workshops throughout Australia and publishes a bi-monthly clinical update, focusing on effective treatment approaches to common health problems.

End Notes

1. This is the rendering used by Ted Kaptchuk in the 2000 edition of Chinese Medicine – the Web that has no Weaver, p.82. His exposition on the psychological aspects of TCM, although brief, is, in my opinion, excellent.
2. I have deliberately placed ‘Qi’ inside brackets as this passage makes more sense if we take the Chinese character ‘Qi’ to refer to Qi in the broad sense, in which case its use is purely rhetorical and can be omitted in an English translation.
3. This is the preferred viewpoint of the author, and is thus the ‘filter’ through which the information presented here has been processed.
4. Yue Ju Wan, developed by Zhu Dan Xi to treat various types of stagnation (Qi stagnation, Blood stasis, Heat stagnation, Phlegm-Damp stagnation and food stagnation). The name of this formula is variously translated as ‘Escape Restraint Pill’; ‘Overcome Depression Pill’; ‘Pill for Five Types of Stagnation’ etc.
5. For this insight I am indebted to an article by Scheid and Bensky, ‘Medicine is Signification - Moving Towards Healing Power in the Chinese Medical Tradition’.
6. This paper adopts a primarily ‘TCM herbal’ approach. Thus, a discussion of the role and significance of the Pericardium is beyond its scope. There is no doubt that treating the Pericardium with acupuncture may have a profound effect on a patient’s mood; this is a commonly observed occurrence in the clinic. However, I will leave the exploration of this topic for another paper and perhaps another author.

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Depression: Towards an Integrated Approach - Part Two

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