Clinical Depression and TCM: (Part One)
Before the 1980’s the national publication of the Traditional Chinese Medicine textbook contained very little information on common psychological problems such as depression and anxiety. When modern Western psychiatry was introduced into China during that decade, there was no equivalent entity in Chinese medicine to correspond to a diagnosis of Clinical Depression. Chinese psychiatrists defined ‘Depression’ by borrowing traditional pathogenic term yu (see below) and qualifying it with ‘suppress’.
In contemporary TCM, the term ‘yu’ is reserved to describe the stagnation of the qi that is associated with emotional strain and centres on liver dysfunction. In most contexts this signifies an inability to express one’s emotional responses, marked by irritability and a sense of frustration. The alternative, relatively newer term: zhi, is used in reference to qi to denote stagnation or sluggish movement in a general sense without necessarily implying emotional causes.
In modern transmissions of TCM theory, the precise nature of the relationships between an individual’s psychic life and organs are generally described with lists of correspondences between an organ and various emotions and mental faculties.
According to the Ling Shu, Scroll 2 Chapter 8:* “When the liver is deficient, fear will occur; when there is excess, one will become angry. When the heart is deficient, sorrow will occur; when there is excess, unceasing laughter will occur.” This is the only reference in the entire Nei Jing (the oldest typical TCM book) to emotions ’coming from’ organs. Thus, according to the major classical source of Chinese medicine, only the liver and, more specifically, the heart are capable of generating and affecting emotions.
While the effects of various emotional states may gravitate to different organs and disrupt their normal functions, the psychic aspects of the heart and liver alone are always held to be the primary source of all facets of our emotional life, whether positive or negative. Therefore, in the diagnosis and treatment of depression, we need to focus primarily on the heart and the liver.
The original classics of TCM have a spiritual orientation manifest in the belief that the forces of the spirit and qi dominate all matter including the human body and spirit. 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 cure the physical body one must first heal the spirit.’ This is diametrically opposed to the orientation of Chinese medicine text from contemporary China, which places physical causes in the leading role.
Part two The Five Phases or Five Elements theory provides a useful framework for understanding depression. Viewed in simple terms, depression may be best defined by what is absent from the psyche of the depressed individual, compared with what is present in the normal healthy individual, namely:
· A sense of joy
· The ability to respond emotionally and express emotions
· The ability to give significance or meaning to things
The first related to fire; the second to wood; the third to earth. Thus we have failure in these three aspects of the Five Elements, implicating the involvement of heart-pericardium, liver and spleen in the pathogenesis of depression. In light of the above discussion, the liver and heart disorder are primary, while spleen deficiency is secondary.
The main contributing factors may be categorized as:
The experience of prolonged or intense emotional strain
· Lack of emotional self-control
· Imbalance between work and leisure
· Excessive mental work
· Lack of clearly defined value system
· Lack of harmonious interpersonal relationship
· Failure to cultivate harmony with nature
· Lack of personal integrity
· Neglect of self-cultivation
· Inaccurate self-knowledge
Any, or a combination of, the above may weaken the spirit and lead to the development of specific organ system imbalances. For the purposes of clinical diagnosis and treatment, four major syndrome-patterns may be described for patients presenting with a depressed mood, signifying the core pathodynamics of this condition:
· Liver qi constraint
· Instability of the heart qi
· Heart-blood and spleen-qi deficiency
· Phlegm clouding the mind and senses
It should be noted that patients mostly present with varying combinations of the above.
A 2004 review of clinical studies concluded that ‘there is insufficient evidence to determine the efficacy of acupuncture compared to medication, or waiting 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 improving depression’ defined as remission. 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’. 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’.
Both animal and human studies have shown that acupuncture is able to modulate central neurotransmitters, which may be the key to its’ observed effect on mood regulation.
Based on the European Journal of Oriental Medicine, p32-47 Vol6. No.5.2010-11
‘Based on the material discussed above, I propose that patients with a clear diagnosis of clinical depression should be referred to a qualified psychiatrist for assessment and only receive antidepressant medication under this level of professional guidance. Other therapeutic modalities may provide a supporting role, e.g. cognitive psychotherapy, adoption of a healthy lifestyle together with TCM treatment. The initial aims of this combined approach would be improvement of mood, detection and correction of contributing factors (through psychotherapy, counselling, nutrition, physical fitness, stress management) and balancing the physiology (with acupuncture and Chinese herbal medicine). The 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 treatment would continue until physiological balance has been established.’