Yuhang Qi, L.Ac., Ping Gong, L.Ac

Depression, recognized as a pervasive mood disorder seen in clinical settings, is primarily characterized by persistent low mood and loss of interest, with severe cases posing risks of self-harm or suicide. It is identified as one of the most serious mental illnesses and has become the leading cause of disability worldwide. The World Health Organization predicts that by 2030, depression could become the leading cause of global disease burden [1]. Current mainstream treatment approaches for depression are largely based on the monoamine deficiency hypothesis, which suggests that the onset of depression is related to the deficiency or reduced activity of one or several neurotransmitters in the brain, such as serotonin, norepinephrine, and dopamine [2]. However, considering the brain’s complexity with over a hundred neurotransmitters and billions of neuronal connections, this hypothesis seems overly simplistic. Therefore, traditional antidepressants targeting single molecules have limited effects and are insufficient to address the complexity of depression fully.

In Traditional Chinese Medicine (TCM), depression is referred to as “Yu Syndrome.” TCM has a long history of treating depression with unique advantages. Due to its significant clinical efficacy, lower side effects, and higher compliance, it is widely used in clinical settings. Although TCM does not have a specific term for depression, many records related to it exist, with different names given based on clinical manifestations, such as “Bai He Bing,” “Dian Bing,” “Zang Zao,” “Mei He Qi,” and “Ben Tun,” all falling within the scope of depression [3,4]. Huang Di Nei Jing describes “Five Stagnations” caused by imbalances in the five elements. Su Wen · Liu Yuan Zhi Ji Da Lun chapter records: ” Wood stagnation releases it, fire stagnation initiates it, earth stagnation takes it, metal stagnation drains it, water stagnation breaks it; then regulate its Qi, the excessive is broken, due to its fear, that is called draining it [5].” Danxi Zhu of the Yuan dynasty first proposed the concept of “Six Stagnations,” suggesting in Dan Xi Xin Fa on Six Stagnations that harmony within qi and blood prevents all diseases, and any stagnation leads to various illnesses, thus, many diseases arise from stagnation [6]. Yi Xue Zheng Zhuan states, “The so-called Six Stagnations are qi, dampness, heat, phlegm, blood, and food [7].” Additionally, Jingyue Zhang of the Ming dynasty introduced “Three Stagnations” in his Jing Yue Quan Shu · Yin Shi Men, namely anger stagnation, pondering stagnation, and sorrow stagnation, which clinically resemble the main manifestations of depression closely [8]. Zhang further detailed how anger damages the liver, leading to failure in spreading and draining, causing liver wood to oppress spleen earth, resulting in spleen deficiency and consequently affecting the heart, kidneys, and other organs.

The clinical manifestations of depression involve both mental and physical symptoms. Mental symptoms include unrest, depressed mood, disappointment, loss of interest, sighing, easy sadness, sleep disorders, anxiety, sluggish thinking, lethargy, emotional instability, and loss of work and social abilities, sometimes leading to suicidal thoughts. Physical symptoms include frequent headaches, dizziness, chest tightness, palpitations, shortness of breath, loss of appetite, nausea, plum pit qi, and more. In women, more gynecologic issues are observed. The high incidence and severity of depression in modern society, leading to a high suicide rate, are closely related to the stress and pressure of daily work and life. Stress and pressure are primary causes of liver qi stagnation, which is a common initial stage of depression. In summary, depression has become a serious disease affecting human health in modern society, causing significant harm to patients and their families.

In recent years, due to the continuous development of TCM, the treatment of depression with acupuncture and herbal medicine has gained widespread recognition for its efficacy, safety, and acceptability. In the clinical practice of TCM treatment for depression, a comprehensive treatment plan is formulated through individualized diagnosis to adjust the patient’s organ functions and restore internal balance. Here are three typical clinical case analyses:

Case 1:

A 37-year-old unmarried white female presented with difficulty falling asleep, low mood, unprovoked anger, loss of interest in things, and a feeling of extreme loneliness, with occasional suicidal thoughts, 8 months after a breakup due to occupational stress. Diagnosed with severe depressive disorder by Western medicine, she was prescribed fluoxetine, which provided temporary relief but was discontinued due to side effects, leading to recurrent symptoms. Therefore, the patient explored natural medicine. No family history of depression was reported. Symptoms at consultation included lack of energy, slow actions, difficulty communicating, low mood, insomnia, chest pain, irritability, dry mouth, constipation, menstrual issues, breast tenderness, dark red tongue with a yellow coating, and a slippery rapid pulse.

TCM diagnosis was liver qi stagantion transforming into fire, treated with clearing heat and move the liver qi. Acupuncture was performed on LR-3 (Tai Chong), SP-6 (San Yin Jiao), LR-14 (Qi Men), HT-7 (Shen Men), LI-4 (He Gu), PC-6 (Nei Guan), N-HN-54 (Anmian), and M-HN-3 (Yintang) points using 0.25mm x 40mm needles. After local disinfection, the needles were quickly inserted using the tapping method and manipulated until the patient felt the de qi sensation. An electroacupuncture device connected LR-3 with SP-6 and LI-4 with HT-7, setting the frequency to 2Hz and adjusting the electric current intensity based on the patient’s tolerance. Each treatment lasted 25 minutes, twice a week.

Herbal treatment used concentrated herbal powder based on modified Dan Zhi Xiao Yao Tang and Zhi Zi Chi Tang including Chai Hu 12g, Zhi Zi 9g, Mu Dan Pi 9g, Dou Chi 9g, Bai Shao 15g, Yu Jin 9g, Xiang Fu 9g, Qing Pi 9g, Huang Bai 9g, Huang Lian 9g, Ge Gen 9g, Chao Zao Ren 15g, Zhen Zhu Mu 15g. The patient took 8g twice daily, morning and evening. Additionally, 15 minutes of mindfulness meditation daily [9] and supplementation with essential fatty acids (Omega-3) and creatine were recommended [10,11].

After three treatments, the patient reported being able to fall asleep quickly at night, with significant improvement in the mentioned symptoms and almost normal sleep patterns, a more pleasant mood, and significantly reduced irritability. After six treatments, the symptoms were essentially gone. Nine consolidation treatments were conducted, and the patient remained in good condition without discomfort.

This case illustrates the effectiveness of combining acupuncture and herbal medicine in treating depression with almost no adverse reactions. TCM theory considers emotional injury as one of the main causes of depression. Prolonged worry and mental tension can disrupt the liver’s ability to regulate qi, leading to stagnation and, ultimately, depression and liver fire harming the heart and kidneys. Therefore, acupuncture primarily targets points along the heart, liver, and kidney meridians. Herbal treatments focus on clearing heat and cooling the liver. Combined with modern research, numerous articles published in authoritative journals indicate that mindfulness meditation, essential fatty acid, and creatine supplementation can effectively improve symptoms of depression.

Case 2:

 A 36-year-old Eurasian male, single, with a family history of mental illness and family upheavals since childhood, suffered from depression and anxiety starting in high school, which worsened with work stress, leading to several panic attacks characterized by a sensation of burning, palpitations, sweating, chest tightness, and difficulty breathing, necessitating emergency room visits. The patient typically felt low, avoided social interactions, was irritable, had fluctuating sleep quality with nightmares, felt sad upon waking, and was reluctant to go to work, with reasonable appetite but post-meal discomfort and slow digestion, sometimes experiencing nausea and general muscle tension. The patient looked downcast, had lackluster eyes, and hesitated in conversation, darkish tongue with a yellow coating and a wiry thin pulse. Despite years of antidepressant medication and regular sessions with a psychologist, along with extensive physical exercise to alleviate anxiety, the results were unstable. TCM diagnosed him with typical liver qi stagnation transforming into heat and heart blood deficiency. As the patient feared acupuncture, the treatment focused on herbal medicine and Tuina therapy.

The herbal formula consisted of concentrated herbal powder with Chai Hu 9g, Bai Shao 12g, Dang Gui 12g, Zhi Ke 9g, Sheng Di Huang 12g, Zhi Zi 9g, Suan Zao Ren 12g, Yuan Zhi 12g, Fu Shen 12g, Dai Zhe Shi 12g, Fu Xiao Mai 15g, Gan Cao 9g., taken twice daily, 8g each time. After one week, re-evaluation showed improvement, with notably better sleep. However, slight nausea occurred after taking the medicine. Continued with the previous formula, doubled the dosage, added Ban Xia 9g, Sheng Jiang 6g, and followed the same method for two more weeks. At the third visit, the patient reported significant improvement, relaxed and stable mood, no panic or anxiety, better sleep duration and quality, and a willingness to interact and socialize. Requested to continue the treatment. In the second formula, Dai Zhe Shi was removed, He Huan Pi 15g was added, and the dosage was increased to a month’s supply. By the fourth visit, the patient felt very good and wished to continue with the third formula, totaling six months of medication.

Herbal formula analysis: Chai Hu, Bai Shao, Dang Gui, and Zhi Ke primarily softened the liver, dredged the liver, and regulated qi, aiming to relax the patient mentally; Sheng Di Huang, Zhi Zi, and Dai Zhe Shi cleared liver heat, cooled the liver, aiming to eliminate irritability and calm the mind; Suan Zao Ren, Yuan Zhi, Fu Shen, and Fu Xiao Mai nourished the heart and spirit, aiding in sleep, to ensure the patient got adequate rest. The second consultation added Ban Xia and Sheng Jiang to harmonize the stomach and stop nausea; the fourth consultation removed Dai Zhe Shi, a mineral medicine that is heavy and can harm spleen and stomach yang qi, replacing it with He Huan Pi to relieve liver stagnation and calm the spirit.

During the course of taking Chinese herbs, continued with antidepressant medication and weekly Tuina therapy. The Tuina focused on the head, chest, and back, mainly pressing GV-20 (Bai Hui), GB-8 (Shang Xing), GV-24 (Shen Ting), GB-9 (Tai Yang), CV-17 (Shan Zhong), CV-15 (Jiu Wei), CV-17 (Dan Zhong), BL-15 (Xin Shu), LR-14 (Qi Men), GB-24 (Ri Yue), SP-21 (Da Bao) and other points. These acupoints helped relieve depression and anxiety.

Case 3:

A 54-year-old Asian male patient presented with a primary complaint of insomnia lasting more than five years, accompanied by a decline in mood and weight loss. Five years prior, conflicts at work led to anger and difficulties falling asleep at night, frequent awakenings, and reliance on non-prescription sleep aids for rest, which resulted in reduced sleep quality and frequent dreaming. The recurring episodes of insomnia worsened after a year, not only persisting but also accompanied by depressive moods, mental distress, excessive worry, and occasional disorientation, prompting a consultation with Western medicine and a diagnosis of “depression”. The patient began treatment with two types of antidepressants, which slightly alleviated symptoms but caused side effects such as fatigue, particularly weakness in the lower limbs, dry mouth, loss of appetite, postprandial bloating, and significant weight loss, leading to seeking acupuncture and herbal medicine treatment. At the initial consultation, the patient appeared mentally exhausted, depressed, seemingly sorrowful, overly contemplative, doubting his own health, leading to restless sleep and difficulty falling back asleep after waking, with a maximum of 3-4 hours of sleep per night, daytime lethargy, inability to concentrate, irritability, aversion to cold with cold limbs, poor appetite, bloating, loose stools, and frequent urination at night, up to 3-4 times. The tongue was pale red with a slightly greasy white coating, and the pulse was deep and slippery. TCM diagnosis identified Yu Zheng, with patterns of spleen and kidney yang deficiency and the hear shen not being nourished. The treatment principle focused on warming and supplementing the spleen and kidneys, nourishing the heart, and calming the spirit. The treatment as follows:

Acupuncture points: the nape line, GV-20 (Bai Hui), M-HN-1 (Si Shen Cong), M-HN-3 (Yin Tang), HT-7 (Shen Men), PC-6 (Nei Guan), CV-6 (Qi Hai), CV-12 (Zhong Wan), CV-10 (Xia Wan), ST-25 (Tian Shu), GB-24 (Ri Yue), LR-14 (Qi Men), SP-9 (Yin Ling Quan), ST-36 (Zu San Li), Feng Long, SP-6 (SanYin Jiao), KI-3 (Tai Xi). The procedure began with needling along the nape line, inserting the needles 0.5 cun deep, twisting and reinforcing for one minute before removal; next, bilateral PC-6 (Nei Guan) points were needled 0.5–0.8 cun deep, applying a twisting and reinforcing method for 30 seconds; then needling M-HN-3 (Yin Tang) obliquely towards the nasal root at 0.5 inches; M-HN-1 (Si Shen Cong) needles were directed towards GV-20 (Bai Hui), inserting 0.3 inches deep, until the patient felt a sensation of soreness and swollen. Other points used standard techniques, applying even reinforcing-reducing methods, with GB-24 (Ri Yue) and LR-14 (Qi Men), needled obliquely at 0.3–0.5 inches, retaining all needles for 20 minutes, including using electroacupuncture on SP-6 (SanYin Jiao) and KI-3 (Tai Xi) for the same duration. Additionally, the patient was advised to perform ginger moxibustion at the CV-8 (Shen Que, navel) three cones per session, once daily. Concurrently, herbal medicine combined Si Ni Tang and Gui Pi Tang with modifications, taken once in the morning and evening. After six treatments, the patient’s sleep improved, extending to 6–7 hours, with reduced nocturnal urination, a more pleasant mood, less anxiety, increased appetite, and significant alleviation of bloating. After 15 treatments, the patient felt significantly better overall, leading to a reduction in antidepressant medication without rebound symptoms. After 30 treatments, the patient gained 4 kilograms and discontinued treatment. The patient continued practicing Tai Chi and walking daily after treatment cessation. At a six-month follow-up, he reported good sleep quality, a pleasant mood, and no discomfort.

Case analysis: The patient’s distress led to liver qi stagnation and liver overacting on spleen, damaging spleen qi, subsequently affecting the heart and kidneys, manifesting as insomnia, anxiety, and restlessness. According to the theory of the Five Elements, damage to one organ affects all, making the condition more complex due to years of illness. Spleen deficiency resulted in impaired transformation and transportation functions, poor appetite, bloating, loose stools, weight loss, while liver stagnation consumed blood, and spleen deficiency failed to generate sufficient qi and blood, causing the spirit to be unnourished, leading to insomnia, excessive pondering, lack of concentration, and disorientation; long-term spleen deficiency caused spleen and kidney yang deficiency, weakening life gate fire, manifesting as aversion to cold with cold limbs, and frequent nocturnal urination, among others. Acupuncture, moxibustion and herbal treatments all aimed to warm and supplement spleen and kidney yang, enhancing the spleen’s functions, generating blood to nourish the spirit, and warming kidney yang to reduce nocturnal urination. The combination of acupuncture and herbal medicine addressed the root causes and achieved significant results, illustrating the effectiveness of integrating TCM principles in treating complex conditions like this patient’s insomnia and associated depressive symptoms.

Reference

Lépine, J. P., & Briley, M. (2011). The increasing burden of depression. Neuropsychiatric Disease and Treatment, 7(Suppl 1), 3-7.

Hindmarch, I. (2002). Beyond the monoamine hypothesis: Mechanisms, molecules, and methods. European Psychiatry, 17(S3), 294s-299s.

Xie, Q., Yang, Q. L., Wang, Z. X., Wang, H., Zhao, J. J., Li, J., … & Du, J. (2022). Research on the treatment of depression with non-pharmacological therapies in traditional Chinese medicine. Journal of Basic Chinese Medicine, (03), 491-494. doi:10.19945/j.cnki.issn.1006-3250.2022.03.006.10.19945/j.cnki

Du, J., Kong, J. H., & Yang, Q. L. (2020). Theoretical analysis of the mechanism of emotional victory intervention in the treatment of depression. Journal of Basic Chinese Medicine, (06), 739-741.

Tian, D. H. (2005). Clinical Series of Traditional Chinese Medicine: The Inner Canon of the Yellow Emperor (9787117067225th ed.). People’s Health Publishing House.

Zhu, Z. H. (2005). Clinical Series of Traditional Chinese Medicine: Dan Xi’s Heart Method (9787117067119th ed.). People’s Health Publishing House.

Yu, T. (2007). The Correct Transmission of Medicine [M]. Beijing: Traditional Chinese Medicine Classics Publishing House, p. 97.

Zhang, J. B. (1994). Complete Works of Jing Yue [M]. Beijing: China Traditional Chinese Medicine and Pharmacy Publishing House, pp. 242-244.

Hofmann, S. G., & Gómez, A. F. (2017). Mindfulness-based interventions for anxiety and depression. Psychiatric Clinics, 40(4), 739-749.

Bloch, M. H., & Hannestad, J. (2012). Omega-3 fatty acids for the treatment of depression: Systematic review and meta-analysis. Molecular Psychiatry, 17(12), 1272-1282.

Kious, B. M., Kondo, D. G., & Renshaw, P. F. (2019). Creatine for the treatment of depression. Biomolecules, 9(9), 406.