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Depression is a mood disorder characterized by feelings of sadness, discouragement, and despair. All of us have experienced such feelings at one time or another, perhaps after a death, a major disappointment, or other trauma. This is a natural and healthy response, and most of us overcome these feelings after a time. However, when these feelings occur without any precipitating factors and are persistent, depression has set in.

Over 28 million (Textbook of Natural Medicine, p. 1040) Americans take antidepressant and antianxiety agents. This is truly an astounding figure. Depression is among the most common of behavioral disorders. Some have even said that it is the "common cold" of psychiatric/psychological problems (What You Need to Know About Psychiatric Drugs, p. 23). In 1994 it was reported that 17.1% of the general American population had a lifetime history of a major depressive episode (Archives of General Psychiatry, 1994;51:8-19). Major depression is one of the fifteen leading causes of disability in developed countries and is projected to become the second leading cause of disability worldwide by 2020 (Lancet, 1997;349:1498-1504).

From another viewpoint, since publication of the Diagnostic and Statistical Manual in 1959, the bible of American psychiatrists, the number of "psychiatric" and "behavioral disorder" cases has increased exponentially.

The inference is that a good portion of these individuals have not been diagnosed, but merely labeled. By diagnosis, one means that an actual cause is found for the presenting emotional symptoms. There are many diseases that have psychological manifestations as part of their symptomatologies. For example, persons with Brill-Zinsser disease, also known as recrudescent rickettsial infection, often show signs of paranoia and despondency. The disease is due to a rickettsial pathogen that lies dormant for years, and then resurfaces to cause rash, fever, headache, and emotional problems such as paranoia, despondency, and hopelessness. In addition to laboratory tests, the key to diagnosis is the often-cyclical onset of these symptoms. Clearly, treatment with antidepressants and anxiolytics does not relieve the condition, only antibiotic therapy does. Other "emotional" problems that are frequently misdiagnosed include "hyperactivity" caused by low-level carbon monoxide toxicity, "conduct disorder" due to asymptomati c beriberi, and even "anxiety" from a thyroid disorder. Therefore, when a person goes to the doctor complaining of an emotional difficulty, in all likelihood he or she will be quickly prescribed a medication to "relieve" the difficulty, instead of being carefully diagnosed to ascertain the root cause.

As Chinese medicine practitioners, we can learn a valuable lesson from this. When diagnosing a patient, we do so through the four techniques of looking, listening and smelling, asking, and palpating. These techniques should be applied across the board to all patients, whether they present with an organic symptomatology, or with emotional problems. In Chinese medicine, emotional presentations are treated just like any other disease, since the seven emotions are intimately connected with the health of an individual. The health of the emotions affects the health of the physical body, and vice versa. In biomedicine, only in recent years has this concept become more accepted, with increasing research focusing on the mind-body connection. Of course, in Chinese medicine this is established empirical knowledge that is now a fundamental part of diagnosis and treatment.

In this article, we discuss how depression is treated with Chinese herbs, and in particular, we address how herbs should be administered to individuals who are also taking pharmaceutical agents such as antidepressants and anxiolytics. Recently, this has become an issue of intense concern in the biomedical community. As practitioners we should be aware of this and make every effort to work with patients who are taking such medications.

Biomedical Perspective of Depression

Symptomatology: There are several types of depression ranging from the normal "blues" to mild depression (dysthymia) to major depression. Normal depressed mood is a healthy reaction to loss or change. It often provides impetus for one to make changes that will render the new situation bearable. Persons with more debilitating depression have feelings of doom and gloom, despair, and hopelessness. They also experience crying for no apparent reason, loss of appetite, fatigue, difficulty concentrating, and insomnia. Another typical complaint is loss of interest in activities they previously found pleasurable. For some, thoughts of suicide are prevalent. Persons with manic-depressive illness, or bipolar disorder, exhibit alternating bouts of depression with episodes of intense excitement and mania. Those with psychotic depression, an extremely severe depression, often have psychotic symptoms such as hearing voices (auditory hallucinations), or delusions.

Etiology: Depression can be either primary or secondary in occurrence. Primary depression comes about without other precipitating physical conditions or diseases, whereas secondary depression is usually the development of preexisting physical or mental disease, or of medications. In terms of the cause of primary depression, the precise pathogenesis is not clear. Bio-psychosocial factors including heredity, stressful life events, personality type, and gender (women have a higher incidence of depression), may interact with each other to cause depression. Research is currently underway to elucidate the biological underpinnings of depression.

Secondary depression can be caused by a medical condition, pharmaceutical medications, recreational drugs, and even by other psychiatric disorders. Physical problems that can lead to depression include infectious diseases, endocrine problems, neurologic conditions, as well as nutritional deficiencies, and cancer. Medications that can cause depression include steroids, amphetamines, certain antibiotics, and narcotic analgesics, among others. Compounding the problem, discontinuing certain medications can also lead to depression. Psychiatric conditions that often have depression as a symptom includes anxiety disorders, schizophrenic disorders, antisocial personality, and alcohol and substance abuse disorders. Therefore, one cannot overstate enough the importance of a thorough diagnosis whenever a patient presents with signs of depression. Often by treating the somatic illness, the depression can be concomitantly resolved.

Treatment: Conventional medical treatment of depression whether mild or severe, is often automatically addressed with medications. While this is an unfortunate sign of the times, there are some bright lights illuminating the way by advocating non medication interventions, such as exercise, nutritional approaches, participating in self-help groups and in counseling. These can be helpful in resolving mild depression, and can be used in combination with medication for more serious forms of depression.

The common psychotherapeutic agents that are currently used include the selective serotonin uptake inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline, citalopram; tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, nortriptyline, and desipramine; heterocyclics such as amoxapine and trazodone; and monoamine oxidase inhibitors (MAOIs) such as phenelzine, isocarboxazid, and tranylcypromine. Other agents such as bupropion and venlafaxine are frequently prescribed for depression in women.

While such medications are undeniably effective when prescribed correctly, adverse effects are all too common. TCAs and MAOIs in particular are known to induce severe side effects. As such, these are less prescribed, with SSRIs now the first-line therapy for depression in the US. Common side effects of antidepressants include cardiovascular problems, sexual difficulties, weight gain, sleepiness, interactions with other drugs, and hypotension. Little wonder then, that an increasing number of people are turning to alternative medicine, including Chinese medicine, for help with depression.

TCM Perspective of the Emotions

According to Chinese medicine there are seven emotions that a person can experience: joy, anger, worry, pensiveness, sadness, fear, and fright. These are normal emotions that are reactions to various life circumstances. Only when they come on suddenly and intensely, or continue for a protracted period do they lead to pathological consequences. It should be remembered that diseases caused by the emotions arise from the interior and directly affect the corresponding organs. This is different from, for example, the Six Excesses, which cause disease by entering the body from the exterior. Thus, symptoms caused by emotional disturbances often manifest very soon after onset. Furthermore, the immediate result is a disturbance of the Qi mechanism, which if untreated causes further disharmonies depending on the affected organ(s).

Symptomatology of Depression: In terms of the western concept of depression, among the seven emotions, the three that are most similar in symptomatologies to depression are worry; anger, and sadness. While these are simple, descriptive terms, the spectrum of presentation of these emotions, i.e., depression, is very wide indeed, and many of them have already been mentioned above. The associated organs of these three emotions are the heart, spleen, and liver. The common syndrome patterns include those related to Qi deficiency, Qi stagnation, blood deficiency, phlegm, and deficiency of both Yin and Yang.

Etiology of Depression. In Chinese medicine, we more often speak of the emotions being the cause of physical symptoms rather than the opposite. Perhaps this is because we see more of these kinds of cases. But practitioners do need to be mindful of the fact that physical syndrome patterns can also lead to emotional disharmonies. For instance, a pattern that involves dampness can affect the spleen. In addition to symptoms such as loss of appetite, loose stools, turbid urine, leukorrhea, the individual may have depression-like manifestations, such as excessive sleeping, moodiness, slowing of thinking, or preoccupying thoughts during which the person continually "spins his wheels" without resolution.

Treatment: In Chinese medicine, depression is treated according to the presenting syndrome pattern. In the cases that we present below, we discuss these treatments individually. In general, for many of our clients, a multipronged approach is used: herbal therapy, reduced dosage of antidepressants, counseling, and other modalities. Most individuals are highly motivated to follow through with this regimen, not wishing to become dependent on antidepressant agents.

Empirical herbal formulas used in the treatment of depression include Aspiration, Calm Spirit, Ease Plus, Shen Gem, and St. John's Seng. Aspiration contains Polygala (Yuan Zhi), which is used to quiet the heart. It has been traditionally used for insomnia, palpitations, and restlessness. In addition Aspiration contains herbal antidepressants, Albizza (He Huan) and Vervain which has been used for several hundred years to soothe the emotions. The remaining herbs: (Uncaria Gait Teng, Gardenia Zhi Zi, Damiana Folium Thrnerae Aphrodisiaciae, White Peony Bai Shao, Tang-kuei Dang Gui, Pinellia Ban Xia, Poria Fu Ling, Aquilaria ChenXiang); resolve dampness, phlegm, and liver qi stagnation. Typically, the pulse will be slow and may be soggy. The tongue may be pale and have a white or gray coating.

Ease Plus (Chai Hu Long Gu Mu Li. Tang) enters the liver meridian and is therefore best used for liver complaints such as irritability, anger, and frustration. Dragonbone (Long Gu) and Oystershell (Mu Li) help calm the liver. Empirically these herbs are used for anxiety states and insomnia. Also present in this formula is Bupleurum (Chai Hit) which invigorates liver qi. The remaining herbs: (Ginseng Ron Shen, Ginger Gan Jiang, Pinellia Ban Xia, Scute Huang Qin, Cinnamon Gui Zhi, Rhubarb Da Huang, Saussurea Mu Xiang); balance the specific effects of these herbs. The pulse is wiry or fast and the tongue may be red around the edges.

Calm Spirit is based on the traditional formula Ding Xin Wan. This formula is used to address heart yin deficiency. It is particularly useful for anxiety-based depression and insomnia. This formula contains Biota (Bai Zi Ren) which is traditionally used for irritability, insomnia, and forgetfulness. Enzymes quench free radicals created during stress, and the calming nutrients included are Magnesium and Taurine. Poria spirit (Fu Shen) is especially known for its spirit quieting effects. In addition, Calm Spirit contains: (Peony Bai Shao, Tang-kuei Dang Gui, Polygala Yuan Zhi, Zizyphus Suan Zao Ren, Ophiopogon Mai Men Dong, Codonopsis Dang Shen, Succinum Ha Po). The pulse may be fast, and the tongue dry.

Shen Gem (Gui Pi Wan) is indicated for heart blood deficiency. This formula is best suited for someone with pale complexion, who has difficulty falling asleep, withdrawal, forgetfulness, and palpitations. The chief herbs in this formula are Ginseng (Ren Shen) and Astragalus (Huang Qi) which are among the strongest Chinese herbs for improving the spleen. Longan (Long Gan Rou) and Zizyphus (Suan Zao Ren) are specific ingredients which have calming effects. The remaining herbs (Poria Fu Ling, White Atractylodes Bai Zhu, Tang-kuei Dang Gui, Salvia Dan Shen, Amber Ha Po, Polygala Yuan Zhi, Saussurea Mu Xiang, Ginger Gan Jiang, Licorice Gan Cao, Cardamon Sha Ren) are for dampness, Qi stagnation, blood stagnation, and blood deficiency. The pulse would be thin and weak, and the tongue pale. A specific formula, St. John's Seng, combines the classical Gui Pi Wan formula with the well-known antidepressant St. John's wort.

These formulas can be taken with pharmaceutical medications and are best used with counseling, daily stress reduction and exercise programs. Herbs should be considered for at least three months as they address long-standing patterns. Individuals who are on multiple medications should be advised to take herbs at least two hours apart from pharmaceuticals, in order to minimize potential interactions. Practitioners should also advise clients to watch for untoward signs and symptoms, and to notify them immediately if such effects appear. Clearly many patients who have been on pharmaceuticals for a long period cannot and should not stop abruptly, lest withdrawal symptoms set in. Many antidepressant medications are highly addictive. Therefore, when individuals do wish to reduce or discontinue their medications, it should be done slowly by tapering the dosage after consulting with their prescribing physician.

The following cases demonstrate the use of Chinese herbs with antidepressants. Future articles will include case studies using herbs alone.

Case 1

Gus, a 45 year-old, prison guard was brutally attacked while at work. Since the attack one year ago he suffered from insomnia, constant headaches, fear (he became withdrawn) and chronic muscle pain, especially shoulder and neck pain. His medications included Percodan (oxycodone hydrochloride) for pain, Flexeril (cyclobenzaprine hydrochloride) for muscle pain and spasm, and Effexor (venlafaxine), an antidepressant. Gus was in weekly counseling. His pulse was thin and wiry; his tongue was slightly pale and red around the edges.

Gus' goals for herbal therapy were to minimize his medication, reduce headaches, and relieve chronic pain. We suggested Ease Plus (Chat Ha Ma Li Long Ga Tang) 3 tablets qid, to relieve liver Qi stagnation and to treat headache, shoulder and neck pain; and Shen Gem, 3 tablets qid, to nourish blood and treat anxiety and insomnia from Qi and blood deficiency. He was instructed to take herbs and drugs 2 hours apart. After two weeks Gus saw a slight lessening of his insomnia and headaches. As he reduced his Percodan dosage 50% he also noticed his mind felt clearer. Gus maintained the herb recommendations for 3 months. He was able to reduce his Percodan dosage 90% and discontinue the Flexeril. Headaches, insomnia, and muscle pain were reduced substantially.

Case 2

Allen was 47 year-old accountant, who had been diagnosed and treated for Hodgkin's lymphoma with chemotherapy treatments six months before visiting our clinic, He complained of fatigue, depression, and nighttime urination, which woke him up and made it difficult to go back to sleep, as he would think about his worries. He was depressed because his father, uncle and grandmother all died of cancer, and he was going through a divorce. Allen was currently being treated with acupuncture and was taking antioxidant vitamins to help his immune system. Allen's pulse was thin and weak; his tongue was red with a thin yellow coating. We recommended Astra Essence which contains: (Astragalus root and seed Huang Qi and Sha Yuan Ji Zi, Ligustrum Nu Zhen Zi, Ho-shou-wu He ShouWu, Lycium fruit Gou Qi Zi, Rehmannia Shu Di Huang, Eucommia Du Zhong, Cuscuta Th Si Zi, Ginseng Ren Shen, Tang-kuei Dang Gui, Cornus Shan Zhu Yu) 3 tablets qid, to tonify his body and stop nighttime urination; and Aspiration which contains: (Polygala Yu an Zhi Vervain Herba Verbenae Officinalis, Uncaria Gou Teng, Gardenia Zhi Zi, Albizzia flowers He Huan Hua, Damiana Folium Thrnerae Aphrodisiaciae, White Peony Bat Shao, Tang-kuei Dang Gui, Pinellia Ban Xia, Poria Fu Ling, Aquilaria Chen Xiang); 2 tablets qid, for depression. After being on the herbs for one month, he reported better energy, less nighttime urination, although he was still depressed. Shortly after starting the herbs he saw a psychiatrist and was prescribed Serzone (nefazodone), an antidepressant. His pulse and tongue were unchanged.

We kept Allen on the same protocol of herbs, suggesting that he take the herbs and the antidepressant two hours apart. As Allen had a great deal of trouble taking the herbs four times a day, he took the same number of tablets two times per day. Gradually, we tapered down the dosage, so he was taking Astra Essence, 3 tablets bid, plus Aspiration, 2 tablets bid. After another month on the herbs and the antidepressant, Allen was no longer depressed, although he still felt sad about his divorce and fearful about the return of cancer. Allen remained on the protocol for over a year. Tests showed the cancer was not growing.

Case 3

Ed has been in a hunting accident 5 years ago where he was accidentally shot at close range with a shotgun, requiring numerous surgeries. Since this incident Ed was on disability. He was in chronic pain and suffered from insomnia, depression, fatigue and migraine headaches. He was currently on Desyrel (trazodone hydrochloride), and Effexor (venlafaxine); he also took ibuprofen every four hours. His pulse was wiry and his tongue was red and dry.

We started him on Ease Plus 3 tablets qid and Posomon oil, containing (Menthol, Peppermint oil, Cinnamon, Tea oil, Licorice, and Scutellariae root); massaged into painful joints and muscles twice or more per day. We suggested that Ed walk every day and try to enroll in a tai chi or yoga class. After two weeks there was little change, although Ed thought the Posomon massage administered by his wife was slightly helpful. At this point we changed Ed's protocol to Ease Plus (two tablets qid) and Channel Flow which contains: (Corydalis Yan Hu Suo, Angelica Bai Zhi, Peony Bai Shao, Cinnamon twig Gui Zhi, Tang-kuei Dang Gui, Salvia Dan Shen, Myrrh Mo Yao, Frankincense Ru Xiang, Licorice Gan Cao); 2 tablets qid. After one month there was little improvement. When questioning Ed further, he had failed to walk most days, and had not enrolled in a yoga or tai chi class. We suggested that if he wanted to function more normally that these activities would be necessary. At this point we decided to concentrate on pain reliev ing strategies. Therefore his new protocol was AC-Q, which is specific for joint and muscle pain. AC-Q contains: (Clematis Wei Ling Xian, Ginseng Ren Shen, Siler Fang Feng, Saussurea Mu Xiang, Ho-shou-wu He Shou Wu, Rehmannia Shu Di Huang, Lindera Wu Yao, Chiang-huo Qiang Huo, Tangkuei Dang Gui, Gastrodia Tian Ma, Cinnamon Bark Rou Gui, Aquilaria Chen Xiang, Frankincense Ru Xiang, Coptis Huang Lian, Blue Citrus Qing Pi, Cloves Ding Xiang, Gentiana Qin Jiao, Achyranthes Niu Xi, Loranthus Sang Ji Sheng, Borneol Bing Pian, Asarum Xi Xin); 2 tablets qid, and Channel Flow 2 tab qid as well as the Posomon massage. Three months later Ed was walking every day and had enrolled in a tai chi class. Over time we changed his protocol to a more tonifying regimen, using Marrow Plus which contains: (Milletia Ji Xue Teng, Hoshou-wu He Shou Wu, Salvia Dan Shen, Codonopsis Dang Shen, Astragalus Huang Qi, Ligusticum Chuan Xiong, Raw Rehmannia Sheng Di Huang, Cooked Rehmannia Shu Di Huang, Lycium Gou Ji Zi, Tang-kuei Dang Gui, Lo tus Seed Lian Zi, Citrus Chen Pi, Red Date Extract Da Zao, Oryza Gu Ya, Gelatinum E Jiao), to strengthen his blood and Qi.

Case 4

Margret was a 38 year-old sales professional with a 20-year history of manic depression; she also suffered from panic attacks, PMS, constipation, and migraine headaches. The chief reason for her visit was insomnia that interfered with her work. She was up between 1-3 am every night and was having difficulty getting up in time for work. She was exhausted most days due to lack of sleep. Margret had tried lithium and all major antidepressants and anti-anxiety drugs. She was under the care of a psychiatrist who prescribed Tegretol. Margret's pulse was wiry and her tongue was red and dry.

Initially we recommended Ease Plus 3 tablets bid to treat her liver imbalance according to Traditional Chinese Medicine. Margret was advised that she needed to be patient in order to see results from the herbs. She was instructed to take herbs and drugs two hours apart. It was explained that her insomnia between 1-3 am, PMS, and migraines were all considered to be due to a liver imbalance, and to effectively treat this condition, time was needed. We also suggested she minimize alcohol -- she was a nightly wine drinker -- and reduce coffee. She reported she needed six cups a day of coffee or more because she was exhausted during the day.

After two weeks there was no change. At this point we recommended adding Schizandra Dreams, before bed and if she woke up, to help her sleep. When she saw that one of the ingredients was Kava Kava, she refused to take it since she had taken Kava before and reported that it caused hallucinations. Therefore we recommended Florased Valerian (Valerian root tincture), 30 drops before bed and upon waking up. After two more weeks Margret reported that the Valerian seemed to make it easier for her to go back to sleep, however there were few other changes.

Next, we recommended that she increase her dosage of Ease Plus to 3 tablets tid, and maintain on the Valerian. After one month on the new protocol, Margret reported a slight improvement in all her symptoms. She reported feeling more "centered and calm." Margret had been successful at reducing her coffee to 3 cups a day, and had reduced her wine drinking to 2 days per week. As she was still constipated we recommended she add 1-3 tbsp. per day of freshly ground flax seeds or flaxseed oil to meals. Over the next 3 months Margret noticed major improvements in all her symptoms. For example rather than waking up every night she was only waking up a few times per week; her migraines were reduced but not eliminated, her PMS was significantly better, and she reported feeling more calm. Her pulse was less wiry and her tongue was normal colored but still dry. We suggested that Margret go off the Ease Plus and substitute Ecliptex which contains: (Eclipta Concentrate Han Lian Cao, Milk Thistle (Sylibum) Sylibum marianum, Curcuma Yu Jin, Salvia Dan Shen, Lycium Fruit Gou Qi Zi, Ligustrum Nu Zhen Zi, Bupleurum ChaiHu, Schizandra Wu Wei Zi, Tienchi Ginseng San Qi, Tangkuei Dang Gui, Plantago Seed Che Qian Zi, Licorice Gan Cao), however Margret was reluctant to go off the Ease Plus, as it had worked so well. Therefore, we had her take both preparations. She now took Ease Plus 2 tablets tid and Ecliptex 2 tablets tid with Florased Valerian (30 drops before bed, and as needed if she woke up), and Flaxseed oil, 3 tbsp. per day with meals. Margret is currently doing well on the new protocol.

Discussion

Bipolar disorder is characterized by major depression alternating between mania and excitement. The standard treatment, Lithium, was prescribed for Margret, but she did not like taking the drug, and through a good deal of trial and error including combinations of antidepressants and anti-anxiety agents, Tegretol was selected. A common side effect of Tegretol is abnormal liver function. Although standard tests revealed only slightly abnormal liver function, her symptoms, as well as her wiry pulse indicated liver imbalance according to TCM. Therefore the herbs we selected -- Ease Plus and Ecliptex -- were aimed at improving her liver. Valerian was selected because she had previously had an unusual reaction to Kava Kava; Flaxseed was selected as it treats constipation. Margret was very eager to try natural therapies, and during the time we treated her she also did a course often acupuncture treatments which probably helped improve her results. As she seemed responsible and was under the care of a psychiatrist, w e saw no reason not to try herbs, as an adjunctive therapy to medication and counseling.

COPYRIGHT 2001 The Townsend Letter Group
COPYRIGHT 2001 Gale Group