Depression is a condition brought about by pent-up passions and impeded Qi movement. In addition to the pent-up emotions, it manifests mainly as emotional lability, chest fullness or tightness, subcostal distention or pain, and globus hystericus.
Etiology and Pathology
The passions are the primary causative factors in depression. When the regulation of the emotions becomes impaired, the liver’s ability to disperse and transport and the heart’s ability to govern the mind become compromised.
However, whether or not this loss of regulation actually leads to illness will depend upon a number of factors. These include the state of the organic body as well as the degree of severity and duration of the emotional imbalance. For example, a patient with a chronically high level of liver activity is more prone to illness on being emotionally frustrated. Conversely, if the object of prolonged brooding or planning is unattained or pent-up rage is unreleased, the liver may lose its smooth functioning and liver-Qi may stagnate, causing chest and subcostal distention and pain. Stagnant liver-Qi can transform into Fire, which if persistent leads to obstruction of meridians and stasis of blood. If stagnant Qi transforms into Phlegm, the blocked liver injures the spleen, or there is excessive brooding and anxiety, then the spleen loses its ability to transport and transform so that Dampness accumulates and transforms into Phlegm. This results in an illness of Phlegm accumulation and Qi stagnation. Intermixture of stagnant Qi and Phlegm blocking the throat gives rise to globus hystericus. If heart and spleen Qi become chronically stagnant, there may be anorexia so that the sources for the generation of Qi and blood become reduced. This may lead to two varieties of illnesses. It can lead to poor nourishment of the mind, which in turn produces so-called “visceral restlessness,” that is, emotional lability with proneness to sadness, worry, and weeping. Or, it can lead to an illness of deficiency of both Qi and blood in the heart and the spleen. If gelled Fire persists and damages Yin, the patient may develop an illness of Yin deficiency of the heart and the kidney or one of blazing Fire.
In depression, the main visceral organs affected are the liver and the heart, but other organs may become involved. These include the gallbladder, the spleen, the stomach, the lung, the kidney, the brain and in females the uterus.
In its initial stages, depression is an illness of strength caused by pathogenic factor. Its pathology is principally Qi stagnation, but may involve blood stasis, rise of endogenous Fire, gelling of Phlegm or food retention. If it persists it evolves from an illness of strength to one of deficiency. Because many visceral organs may become affected and the injuries to Qi, blood, Yin and Yang may differ, depression may manifest a variety of symptoms, related variously to the heart, the spleen, the liver and the kidney. Clinically, strength and deficiency may become intermixed, and it is common for the illness, after the initial stages, to become one of deficiency of Qi, blood, Yin or Yang.
The principal clinical symptoms of depression are those of Qi stagnation, such as pent-up and unstable emotions, and chest and subcostal distention and pain. If other stagnation develops there may be other corresponding symptoms. For example, if there is blood stasis as well, then the patient may show distending or stabbing pain in the chest and flank, with fixed location, and the tongue may be cyanotic with ecchymosis or petechiae. If there is gelling of Fire, there may be impatience, irascibility, chest tightness, subcostal pain, acid regurgitation, a dry mouth with bitter taste, constipation, a red tongue with yellow coating, and a taut and rapid pulse. If there is food retention, there may be gastric distention, foul eructation and anorexia. If there is accumulation of Dampness, there may be heaviness in the body, abdominal distention, eructation, a greasy mouth, loose feces or diarrhea. If there is gelling of Phlegm, there may be abdominal distention, a sensation of a foreign object in the throat and a greasy tongue coating. If there is deficiency as well, there may be symptoms associated with the specific deficiency.
In the case of “visceral restlessness” there is absent-mindedness, emotional lability with unpredictable sadness, weeping or laughing, or globus hystericus. These symptoms are of great significance in the analysis of symptoms and in diagnosis.
Depression is most commonly seen in young and middle-aged women. Most patients have a history of melancholy, anxiety, sorrow or fear. The waxing and waning of the symptoms of depression are intimately related to the vicissitudes of the emotions.
Key Points of Analysis
The development of depression is principally due to blockage of the liver-Qi leading to the spleen losing its transportation and transformation functions and the heart losing its nourishment. Though all three organs are generally involved, in deciding treatment it is important to ascertain whether there is stasis of blood, gelling of Fire, accumulation of Dampness or Phlegm, or other conditions of blockage or stagnation. Stasis of blood, stagnation of Qi and gelling of Fire are mostly related to the liver. Food retention, Dampness and Phlegm accumulation are mostly related to the spleen. Deficiency, on the other hand, is most intimately related to the heart.
In diagnosis a critical differentiation is between strength and deficiency. However, strength and deficiency can transform into each other. For example, stagnation of liver-Qi and accumulation of Phlegm are both illnesses of strength. In persistent illness, if they injure the heart and the spleen they may lead to deficiency of Qi and blood, and this in turn may develop into insufficiency of the heart and the spleen. If they injure the liver and the kidney they may lead to depletion of Yin-essence, and this in turn may develop into deficiency of liver and kidney Yin. Among the deficiency illnesses causing depression the condition of stagnant Qi transforming into Fire often leads to Yin injury by Fire, hence production of blazing Fire due to Yin deficiency.
Deficiency illnesses causing depression can evolve from strength illnesses as well as from melancholic brooding, pent-up rage or other extreme passions damaging the visceral organs and consumption of their Qi, blood, Yin and Yang. In an illness of the latter category the symptoms of deficiency are relatively prominent early in the course. Among the deficiency illnesses, that of mental derangement has its own unique symptoms and needs not evolve from a strength illness. It may result from pent-up anxiety or depletion of heart-Qi, with insufficiency of Nutritive Level blood; either may lead to the heart losing its nourishment, which in turn gives rise to mental derangement. In a patient with prolonged depression, there may also be mixed symptoms of deficiency and of strength. On the one hand, there is deficiency of genuine Qi or depletion of Qi and blood; on the other hand, there is depletion of Yin-essence accompanied by stagnation of Qi, stasis of blood, accumulation of Phlegm or gelling of Fire.
The basic principle in the treatment of depression is to regulate Qi and open orifices. For illnesses of the strength variety it is important to determine whether there is blood stasis, rise of Fire, gelling of Phlegm, accumulation of Dampness or retention of food. These will require the additional use of blood mobilization, Fire purging, Phlegm dissipation, Dampness elimination and digestion promotion, respectively. For illnesses of the deficiency variety it is important to strengthen the visceral organs or to augment Qi, blood, Yin or Yang, depending on the individual circumstances of the patient. This may require the additional method of nourishing the heart and tranquilizing the mind, nourishing and strengthening the heart and the spleen, or nourishing the liver and the kidney as appropriate. For illnesses of the mixed strength-deficiency variety it is important to attend equally to both, or focus more on one or the other as necessary.
In general, depression has a relatively prolonged course. The herbs employed in prescriptions must not be too harsh or potent. In the treatment of depression of the strength variety, focus on regulating Qi without depleting it, mobilizing blood without inducing bleeding, cooling Heat without injuring the stomach, or dissipating Phlegm without damaging genuine Qi. In the treatment of depression of the deficiency variety, focus on strengthening the heart and the spleen without excessive drying, or nourishing the liver and the kidney without dietary excesses.
Stagnation of Liver-Qi
Main Symptoms. Mental depression; emotional lability; chest distention and tightness; subcostal pressure and pain without a fixed position; epigastric bloating and eructation; anorexia; and irregular defecation. The tongue coating is thin and greasy, and the pulse taut.
Therapeutic Principle. Regulate the liver Qi to relieve depression.
Treatment. Chaihu Shu Gan Tang (Bupleurum Liver-Releasing Decoction). It has the following composition: chaihu (Bupleurum) 10 g, xiangfu (Cyperus) 10 g, zhiqiao (Poncirus trifoliata) 10 g, chenpi (Citrus tangerina) 6g, chuanxiong (Ligusticum) 6g, baishaoyao (Paeonia) 10 g, and gancao (Glycyrrhiza) 6g.
If subcostal distention or pain is particularly severe, add yujin (Curcuma), Qingpi (Citrus tangerina, unripe peel) and foshou (Citrus medica L. v. sacrodactylis) to unblock the liver and regulate Qi.
If liver-Qi attacks the stomach, causing impairment of the stomach’s harmonizing and descending functions and giving rise to frequent eructation and discomfort in the chest and epigastrium, add xuanfuhua (Inula britannica), daizheshi (hematite), zisu stalk (Perilla) and processed banxia (Pinellia) to settle the stomach and suppress the abnormally risen Qi.
If in addition there is food retention and abdominal distention, add shenqu (medicated leaven), maiya (Hordeum), shanzha (Crataegus) and jineijin (Gallus gallus domesticus, inner lining of chicken gizzard) to relieve food retention.
If liver-Qi attacks the spleen, giving rise to abdominal distention, abdominal pain and diarrhea, add cangzhu (Atractylodes), fuling (Poria), wuyao (Lindera) and baidoukou (Amomum cardamomum) to strengthen the spleen, eliminate Dampness, warm the channels and stop pain.
If there is blood stasis also, with stabbing chest and subcostal pain and pe-techiae or ecchymoses on the tongue, add danggui (Angelica), danshen (Salvia) and honghua (Carthamus) to mobilize blood and remove stasis.
Stagnant Qi Transforming into Fire
Main Symptoms. Impatience and irascibility, chest and subcostal fullness, and dry bitter mouth; or, headache, red eyes, and tinnitus; or, epigastric distress, acid regurgitation, and constipation. The tongue is red and its coating yellow. The pulse taut and rapid.
Therapeutic Principle. Unblock the liver Qi to relieve depression, clear the liver Heat and purge Fire.
Treatment. Dan Zhi Xiao Yao San (Carefree Powder with Paeonia and Gardenia).
If Fire is severe, with bitter taste in the mouth and constipation, add longdancao (Gentiana) and dahuang (Rheum palmatum) to purge Heat and unblock the viscera.
If Liver-Fire invades the stomach, causing subcostal pain, bitter taste, epigastric distress, acid regurgitation, eructation and vomiting, add huanglian (Coptis) and wuzhuyu (Evodia) to clear the liver, purge Fire, suppress the abnormally risen and stop vomiting.
If Liver-Fire flames upward, causing headache and red eyes, add juhua (Chrysanthemum), gouteng (Uncaria) and jili (Tribulus terrestris) to cool Heat and settle the liver.
If strong Heat injures Yin, producing a red tongue with scant coating and a threadlike and rapid pulse, remove danggui, baizhu and shengjiang (because of their warm-drying action) and add shengdihuang (Rehmannia), maimendong (Ophiopogon) and shanyao (Dioscorea) to replenish Yin and strengthen the spleen.
If chronic Qi stagnation has produced blood stasis, add taoren (Prunus persica) and honghua (Carthamus).
Gelled Phlegm and Qi
Main Symptoms. Mental depression; chest tightness; subcostal distention and pain; and globus hystericus. The tongue coating is white and greasy, and the pulse taut and slippery.
Therapeutic Principle. Mobilize Qi, relieve obstruction, dissipate Phlegm and dissolve gelled accumulations.
Treatment. Banxia Houpo Tang.
If gelled Phlegm has given rise to Heat, producing restlessness and a red tongue with yellow coating, add zhuru (Phyllostachys nigra), gualou (Trichosanthes), huangqin (Scutellaria) and huanglian (Coptis) to cool Heat and dissipate Phlegm.
If fluids are damaged, the mouth dry and the tongue red, remove houpo and zisu stalk and add beishashen (Glehnia) and maimendong (Ophiopogon).
If the illness is prolonged and has entered the collateral meridians, there may be such symptoms as blood stasis, stabbing chest and subcostal pain, a tongue that is cyanotic or speckled with petechiae or ecchymosis, and an impeded pulse. Add yujin (Curcuma), danshen (Salvia), jiangxiang (Dalbergia odorifera) and jianghuang (Curcuma) to Banxia Houpo Tang to mobilize blood and relieve stasis.
Insufficiency of Heart and Spleen
Main Symptoms. Brooding, suspiciousness; dizziness, lassitude; palpitation of the heart; timidity; insomnia, forgetfulness; anorexia; and a lusterless complexion. The tongue is pale, with a white and thin coating. The pulse is threadlike.
Therapeutic Principle. Strengthen the spleen, nourish the heart, augment Qi and generate blood.
Treatment. Gui Pi Tang.
If there is chest tightness with subdued spirit, add yujin (Curcuma) and foshou slices (Citrus medica L. v. sacrodactylis) to regulate Qi and relieve stagnation.
If there is headache, add chuanxiong (Ligusticum) and baizhi (Angelica dahurica) to mobilize blood, dispel Wind and stop pain.
Deficiency of Liver-Yin
Main Symptoms. Dizziness, tinnitus, dry eyes, photophobia, blurred vision; or, expanding headache, facial flushing, red eyes, impatience and irascibility; or, numbness of the limbs and muscle twitching. The tongue is dry and red, and the pulse taut and threadlike or rapid.
Therapeutic Principle. Nourish and replenish Yin-essence and invigorate the liver and the kidney.
Treatment. Qi Ju Dihuang Wan.
If deficiency of liver-Yin is accompanied by hyperactivity of liver-Yang and upward disturbance by liver-Wind causing headache, dizziness, recurrent flushing of the face or muscle twitching, add jili (Tribulus terrestris), gouteng (Uncaria) and shijueming (Haliotis) to calm the liver, suppress Yang and extinguish Wind.
If deficiency of liver-Yin is accompanied by Liver-Fire, add huanglian (Coptis), zhimu (Anemarrhena), baihe (Lilium brownii) and maimendong (Ophiopogon) to replenish Yin and suppress Fire.
If menstruation is irregular, add xiangfu (Cyperus), zelan (Lycopus lucidus) and yimucao (Leonurus) to regulate Qi, relieve depression, mobilize blood and regulate menstruation.
In males with frequent spermatorrhea, consider adding muli (Ostrea), jinyingzi (Rosa laevigata) and Qianshi (Euryale ferox) to strengthen the kidney and astringe essence.
Main Symptoms. Absent-mindedness, restless mind, emotional lability, suspiciousness, and fearfulness; or, frequent yawning and stretching, chorea-like movements, and outbursts of uncontrollable cursing or swearing. The tongue is pale and the pulse is taut.
Therapeutic Principle. Nourish the heart and tranquilize the mind by means of sweet and moistening herbs to ameliorate the urgency.
Treatment. Gan Mai Dazao Tang (Liquorice-Wheat-Date Decoction). It has the following composition: gancao (Glycyrrhiza) 10 g, fuxiaomai (Triticum) 10 g, baiziren (Biota) 10 g, fushen (Poria) 10 g, hehuanpi (Albizia julibrissin) 10 g, yujin (Curcuma) 10 g, foshou (Citrus medica L. v. sacrodactylis) 10 g, and dazao (Ziziphus) five pieces.
If endogenous Wind arises in blood insufficiency, producing twitching of the hands and feet or convulsions, add danggui (Angelica), shengdihuang (Rehmannia), zhenzhumu (Pteria magaritifera, martensii) and gouteng (Uncaria) to generate blood and extinguish Wind.
For irritability and insomnia, add suanzaoren (Ziziphus), roast heshouwu (Polygonum) and other herbs that nourish the heart and tranquilize the mind.
For insufficiency of the heart and the spleen, with lassitude, anorexia, palpitation preventing sleep, consider adding dangshen (Codonopsis), huangqi (Astragalus), danggui (Angelica) and longyanrou (Euphoria longan).
Stagnation of Liver-Qi. Select Qimen (LR-14), Yanglingquan (GB-34), Zhongwan (CV-12), Zusanli (ST-36) and Ganshu (BL-18). Use filiform needles and apply the reducing method.
Gelled Phlegm and Qi. Select Zhongwan (CV-12), Fenglong (ST-40), Tiantu (CV-22) and Taichong (LR-3). Use filiform needles and apply the reducing method.
Failure of Heart-Nourishment. Select Neiguan (PC-6), Shenmen (HT-7), Shuigou (GV-26) and Xinshu (BL-15). Neiguan may be replaced by Jianshi (PC-5), and Shenmen by Tongli (HT-5). Use filiform needles and apply the reinforcing method.
Mental Derangement. Select Neiguan (PC-6), Shenmen (HT-7), Houxi (SI-3) and Sanyinjiao (SP-6). Use filiform needles and apply the reinforcing method. If mental derangement is accompanied by tics of the upper limbs, add Quchi (LI-11) and Hegu (LI-4). If it is accompanied by tics of the lower limbs, add Yanglingquan (GB-34) and Kunlun (BL-60). If it is accompanied by rapid breathing and abnormal Qi movement, add Tanzhong (CV-17).
Case Study 1
The patient was a 46-year old woman. For more than 20 years she had frequent sensation of obstruction by a foreign object in the throat, chest tightness, nausea and dysphagia. She received treatment on many occasions, without benefit. Her pulse was small, deep and slippery.
Diagnosis. Depression caused by liver-Qi rising abnormally and attacking the stomach, and leading to gelling of Phlegm and Qi.
Therapeutic Principle. Unblock the liver-Qi, settle the stomach, suppress the abnormally risen Qi and dissipate Phlegm.
Treatment and Course. The patient was prescribed with a formula based on combined Si Mo Yin (Four-Powdered Drink) and Xuanfu Daizhe Tang Xuanfu Daizhe Tang (Inula and Hematite Decoction). It had the following composition: xuan-fuhua (Inula britannica) (wrapped), calcined daizheshi (hematite), ginger-treated banxia (Pinellia), houpo (Magnolia), yujin (Curcuma), binglang (Areca), zhishi (Citrus aurantium), fried zhuru (Phyllostachys nigra), fuling (Poria) and shengjiang (Zingiber).
Following taking the formula, nausea abated and the sensation of a foreign object obstructing the throat diminished. Treatment was continued with the formula, but without fuling and with added processed chuanlianzi (Melia) and wuzhuyu (Evodia). This modified herbal formula was continued for several weeks, and all symptoms improved.
Case Study 2
The patient was a married woman. For several months she had palpitations of the heart, dizziness, anxiety, periodic shaking, headache, insomnia, much dreaming when able to sleep, spontaneous sweating, chest tightness and anorexia. Her feces tended to be dry, and came once every two or several days. The shaking was sufficiently severe as to cause her bed to creak, and sometimes it came several times a day. Her tongue was pale and her pulse threadlike.
Diagnosis. Depression of the “visceral restlessness” variety, due to mental derangement.
Therapeutic Principle. Nourish the heart and tranquilize the mind.
Treatment and Course. The basic formula used was Gan Mai Dazao Tang (Liquorice-Wheat-Date Decoction), augmented variously during the course by adding Ci Zhu Wan (Magnetite-Cinnabar Pill), suanzaoren (Ziziphus), baiziren (Biota), yejiaoteng (Polygonum multiflorum), daizheshi (hematite), taizishen (Pseudostellaria heterophylla), or fushen (Poria).
There was improvement after 5 day treatment. After about 20 doses, the shaking stopped recurring, her appetite improved and her sleep became more restful. She also began to resume normal physical activity.
Four years later, she came to hospital for another illness. On questioning, she did not have any relapse of depression during these 4 years.