During the Cultural Revolution and for some time after, depression was a politically incorrect term in the People's Republic of China. What is now called depression was, for many years, referred to as "neurasthenia" in China. However, today, depression is accepted as a valid medical diagnosis in China and is a common topic of clinical trials. Below are summaries of three recently published Chinese studies.
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Study 1: From issue #5, 2003 of Beijing Zhong Yi (Beijing Chinese Medicine), Zhang Jin-ru, "The Treatment of 40 Cases of Depression with Xiao Chai Hu Tang (Minor Bupleurum Decoction)," pages 38-39.
Cohort description
Altogether, there were 70 patients enrolled in this study randomly divided into two groups, a treatment group and a comparison group. These 70 patients were either in- or out-patients at the Chinese author's hospital. All were diagnosed with unipolar depression based on Hamilton Depression Scale (HDS) scores and criteria published in Zhong Yi Bing Zheng Zhen Duan Liao Xiao Biao Sun (Criteria for Chinese Medical Disease & Pattern Diagnosis and Treatment Outcomes) published in Nanjing in 1994. Serious depression meant an HDS score of 24 points, moderate depression meant an HDS score of 17 points, and slight depression meant an HDS score of seven points. Among these 70 patients, this was the initial diagnosis of their disease, while in 45 it was a recurrent episode. Eight cases had already been treated with Chinese medicinals, and another 36 had been treated with oral anti-depressant Western medicines.
Within the treatment group, there were 12 males and 28 females aged 21-50 years, with an average age of 32.5 years. These patients had been depressed for 3-12 months, with an average duration of six months. Twenty-three patients were slightly depressed, 15 were moderately depressed, and two were seriously depressed. Eleven of these cases presented a pattern of liver qi depression and stagnation, 14 presented with qi stagnation and phlegm depression, seven with heart-spleen dual vacuity, and eight with yin vacuity-fire effulgence.
In the comparison group, there were nine males and 21 females aged 22-55 years, with an average age of 34 years. These patients had been depressed for 3-13 months, with an average duration of 6.5 months. Nineteen of these patients were slightly depressed, 10 were moderately depressed, and one was seriously depressed. In terms of Chinese medical pattern discrimination, eight cases presented with liver qi depression and stagnation, 11 with qi stagnation and phlegm depression, five with heart-spleen dual vacuity, and six with yin vacuity-fire effulgence. Therefore, both groups were statistically comparable in terms of sex, age, disease duration and severity.
Treatment method
Members of the treatment group all received the following base prescription: Radix Bupleuri (Chai Hu), 10g, Radix Scutellariae Baicalensis (Huang Qin), 10g, Rhizoma Pinelliae Ternatae (Ban Xia), 6g, Radix Pseudostellariae Heterophyllae (Tai Zi Shen), 10g, Radix Glycyrrhizae Uralensis (Gan Cao), 3g, uncooked Rhizoma Zingiberis Officinalis (Sheng Jiang), 3 slices, and Fructus Zizyphi Jujubae (Da Zao), 5 pieces. If there was liver qi and phlegm depression, Pericarpium Trichosanthis Kirlowii (Gua Lou Pi) was added. If there was heart-spleen dual vacuity, Semen Biotae Orientalis (Bai Zi Ren) and Sclerotium Pararadicis Poriae Cocos (Fu Shen) were added, and if there was yin vacuity with fire effulgence, Cortex Radicis Moutan (Dan Pi), uncooked Radix Rehmanniae Glutinosae (Sheng Di), and Radix Albus Paeoniae Lactiflorae (Bai Shao) were added. Three hundred milliliters of water was added to the above medicinals and boiled down to 100ml. The herbs were boiled again down to 100ml, and these two decoctions were added together. Then the resulting medicinal liquid was administered in two divided doses, morning and evening. Thirty days equaled one course of treatment and results were tabulated after two courses.
Members of the comparison group received 20 milligrams of Prozac (manufactured by an American pharmaceutical company) one time each day orally. Thirty days equaled one course of treatment, and two courses were administered.
Treatment outcomes
Marked effect meant that HDS scores dropped to seven points or less, symptoms disappeared, and the mood returned to normal. Some effect meant that the HDS scores decreased to 8-10 points, symptoms decreased, and the mood was basically stable. No effect meant that the HDS score was as high as 18 points and there was no improvement in either symptoms or mood. Based on these criteria, in the treatment group, 21 cases (52.5%) got a marked effect, 16 cases (40%) got some effect, and three cases (7.5%) got no effect, for a total effectiveness rate of 92.5%. In addition, there were no side effects seen in any of these patients. In the comparison group, 11 cases (36.7%) got a marked effect, nine (30%) got some effect, and 10 (33.3%) got no effect, for a total effectiveness rate of 66.7%. Five of these 30 cases developed nausea, vomiting, and indigestion, three developed insomnia, and one developed slight agitation and mania. Therefore, the Chinese medical protocol was markedly more effective than the Prozac and with no side effects.
Discussion
Today, the Western psychiatric category of depression is equated with the traditional Chinese medical disease category of depression, and, according to Dr. Zhang, the Chinese medical cause of depression is damage by the seven affects which then causes liver's loss of coursing and discharge, spleen's loss of movement and transformation, heart spirit's loss of constancy, and the viscera and bowel, yin and yang, qi and blood loss of regulation. Speaking of the six depressions, Zhu Dan-xi said in his Dan Xi Xin Fa (Dan-xi's Heart Methods):
When qi and blood penetrate [or surge] harmoniously, the hundreds of diseases are not engendered. But, once there is depression, any or all diseases may be engendered. Therefore, when a person has any disease, mostly this is engendered by depression. Depression refers to binding and accumulation which does not obtain emission and effusing. That which should be upborne is not upborne. That which should be downborne is not downborne. That which should be changed and transformed does not obtain change and transformation. Thus conduction and transformation lose their constancy and diseases of the six depressions are seen.
Treatment of this disease should be based on the saying from the Su Wen (Simple Questions), "When wood is depressed, out-thrust it." This is why the author has chosen to treat this disease with Xiao Chai Hu Tang. Within this formula, Chai Hu is the ruling ingredient which enters the liver channel. It has the function of regulating and easing the flow of the mind and mood. It corresponds in this formula to the general principles of out-thrusting depressed wood. Huang Qin clears depressive heat. It also restrains Chai Hu's acridity and scattering. Ban Xia downbears counterflow, dries dampness, and transforms phlegm. It acridly opens and bitterly downbears. It is also said, "If one sees liver disease, know that the liver conducts to the spleen; therefore, one must first replete the spleen." Thus Tai Zi Shen and Gan Cao are combined with Sheng Jiang and Da Zao to fortify the spleen, boost the qi, and harmonize the stomach. This also helps invigorate the stomach qi's scattering of evils. When all these medicinals are combined together, their function is to course the liver, rectify the qi, and resolve depression.
Study 2: From issue #9, 2003 of Xin Zhong Yi (New Chinese Medicine), Guo Er-xia, "An Analysis of the Therapeutic Effects of Treating 42 Cases of Depression in the Elderly by the Methods of Supplementing the Kidneys & Transforming Stasis," pages 67-68.
Cohort description
Altogether, there were 62 patients in this study, all over 60 years of age. These 62 patients were randomly divided into two groups, a treatment group of 42 patients and a comparison group of 20. In the treatment group, there were 20 males and 22 females with a median age of 63.4 [+ or -] 1.9 years and a median disease course of 18.1 [+ or -] 6.2 months. In the comparison group, there were 10 males and 10 females with a median age of 62.8 [+ or -] 2.1 years and a median disease course of 17.9 [+ or -] 6.9 months. Therefore, these two groups were statistically comparable in terms of sex, age, and disease duration. In terms of diagnostic criteria, these were based on Zhong Yi Bing Zheng Zhen Duan Liao Xiao Biao Sun (Criteria for Chinese Medical Disease & Pattern Diagnosis and Treatment Outcomes). Clinical symptoms included emotional depression, sorrow, anxiety, a tendency to crying, piercing pain in the head, insomnia, impaired memory, heart and chest vexation and oppression, rib-side and flank piercing pain, low back and knee soreness and limpness, a dry mouth and parched throat, a dark, purple or dark red tongue with possible static macules or speckles, and a fine, choppy pulse. Secondly, all these patients had a score of 40 points or more on the Self-rating Depression Scale (SDS) and eight or more points on the Hamilton Depression Rating Scale (HAMD).
Treatment method
Members of the comparison group were administered 20mg TID of a multivitamin tablet, whereas members of the treatment group received self-composed Di Huang Zhu Yu Tang (Rehmannia Dispel Stasis Decoction): cooked Radix Rehmanniae Glutinosae (Shu Di), 24g, Fructus Corni Officinalis (Shan Zhu Yu), Radix Dioscoreae Oppositae (Shan Yao), Semen Pruni Persicae (Tao Ren), Radix Angelicae Sinensis (Dang Gui), and Radix Cyathulae (Chuan Niu Xi), 12g each, Rhizoma Alismatis (Ze Xie), Sclerotium Poriae Cocos (Fu Ling), Cortex Radicis Moutan (Dan Pi), Flos Carthami Tinctorii (Hong Hua), and Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 9g each, and Radix Ligustici Wallichii (Chuan Xiong), Radix Platycodi Grandiflori (Jie Geng), Radix Bupleuri (Chai Hu), Fructus Citri Aurantii (Zhi Ke), Radix Glycyrrhizae Uralensis (Gan Cao), and Rhizoma Cyperi Rotundi (Xiang Fu), 6g each. If there was abdominal distention, poor appetite, and/or loose stools, Shu Di was either removed or its dose was cut in half. If there was easy agitation and easy anger with a bitter taste in the mouth, yellow tongue fur, and constipation, six grams each of Radix Gentianae Scabrae (Long Dan Cao) and Radix Et Rhizoma Rhei (Da Huang) were added. If there was discomfort in the throat as if there was something stuck, nine grams each of ginger-processed Rhizoma Pinelliae Ternatae (Ban Xia) and Cortex Magnoliae Officinalis (Hou Po) were added. If there was excessive thinking and a tendency to anxiety, sorrow, and crying, then 12 grams each of Tuber Curcumae (Yu Jin) and Flos Albizziae Julibrissinis (He Huan Hua) were added. If there was chest oppression, rib-side pain, and a tendency to great sighing, nine grams each of Fructus Citri Sacrodactylis (Fo Shou) and Pericarpium Citri Medicae (Xiang Yuan). One packet of these medicinals was decocted in water and administered per day in two divided doses. Four weeks treatment equaled one course and results were analyzed after two courses.
Treatment outcomes
Criteria for outcomes in this study were based on Zhong Yi Bing Zheng Zhen Duan Liao Xiao Biao Sun This meant that complete cure was defined as disappearance of symptoms and normalization of the mood. Improvement meant that the symptoms decreased and the mood was basically stable. No effect meant that there was no change in the symptoms. In addition, changes in SDS and HAMD scores were also tabulated.
Based on these criteria, 30 out of 42 patients in the treatment group (i.e., 71.43%) were judged cured, another 10 (23.81%) were improved, and only two (4.76%) got no effect. Therefore, the total effectiveness in this group was reported as 95.24%. In the comparison group, two patients (10%) were cured, six (30%) improved, and 12 (60%) got no effect, for a total effectiveness rate of only 40%. There were also markedly significant mean reductions in both SDS and HAMD scores at four and eight weeks of treatment in the treatment group, while reductions of these two scores at four and eight weeks in the comparison group were not statistically significant. Therefore, for the treatment of depression in the elderly, the Chinese medical protocol was significantly more effective than the multivitamin regimen.
Discussion
According to Dr. Guo, depression in the elderly is primarily the result of varying amounts of kidney vacuity and blood stasis. As evidence of this, Dr. Guo presents the following syllogism: As a person ages, the kidney qi gradually becomes vacuous, and the kidneys are the root of the viscera and bowels. Therefore, if the kidneys become vacuous, the other viscera lose their regulation. Hence the liver loses kidney yin's moistening and nourishment. This results in liver depression and qi stagnation. In that case, qi stagnation, blood stasis, and phlegm may congeal. If the heart loses kidney yin's upward ordering, then the emotions become abnormal. Further, Dr. Guo notes that enduring diseases in the elderly reach the kidneys and enduring diseases mostly involve stasis. Similarly, enduring diseases must involve vacuity, and enduring vacuity must result in stasis. Kidney yang vacuity leads to cold, and cold congelation results in phlegm and stasis. Kidney essence and blood depletion and scantiness lead to withering and astringency of the vessel pathways which may also lead to stasis. For all these reasons, Dr. Guo believes that depression in the elderly should mainly be treated by the methods of supplementing the kidneys and transforming stasis.
Study 3: From issue #4, 2003 of Bei Jing Zhong Yi (Beijing Chinese Medicine), Wang Zhong-ren, "The Treatment of 30 Cases of Post-stroke Depression with Chai Hu Shu Gan San (Bupleurum Soothe the Liver Powder)," pages 30-31
Cohort description
All the patients enrolled in this study were seen as either in- or out-patients of the internal medicine department at the Chinese author's hospital in Tianjin. Altogether, there were 58 patients enrolled in this study. In the treatment group, there were 16 males and 14 females 46-83 years of age with an average age of 58.8 years. These patients had been suffering from post-stroke depression for from 3-12 months, with an average disease duration of six months. In seventeen cases, their disease was light in severity, in 10 cases it was medium or moderate, and in three cases it was heavy or severe. In the comparison group, there were 15 males and 13 females ages 45-80 years, with an average age of 61 years, a disease duration of 3-13 months, and an average course of disease of 6.5 months. Sixteen of these cases were judged light or slight, 10 were medium, and two were heavy or severe. Therefore, there was no statistically significant difference in the members of these two groups in terms of sex, age, or disease duration and severity. All met the criteria for a diagnosis of unipolar depression based on Hamilton Depression Rating Scale scores. Those with a score of 24 points were heavily or seriously depressed, those with a score of 17 were moderately depressed, and those with a score of seven were lightly or slightly depressed. A diagnosis of stroke was based on CT scan and MRI. In the treatment group, 22 cases had suffered cerebral infarction and eight had suffered cerebral hemorrhage. In the comparison group, 22 had suffered cerebral infarction, while the other six had suffered cerebral hemorrhage. Patients with a history of psychiatric disease or a family history of psychiatric disease were excluded from this study. Clinical symptoms of depression included a depressed state of mind, difficult, slowed thinking, decreased speech and activity, decreased appetite, insomnia, and easy waking. If severe, there was extreme sorrow, delusional thinking, or thoughts of self-injury or suicide.
Treatment method
Members of the treatment group received the following augmented version of Chai Hu Shu Gan San: Radx Bupleuri (Chai Hu), 10g, Radix Albus Paeoniae Lactiflorae (Bai Shao), 15g, Fructus Citri Aurantii (Zhi Ke), 10g, Rhizoma Cyoperi Rotundi (Xiang Fu), 10g, Tuber Curcumae (Yu Jin), 10g, Radix Ligustici Wallichii (Chuan Xiong), 10g, Exocarpium Citri Erythrocarpae (Ju Hong), 10g, Sclerotium Poriae Cocos (Fu Ling), 15g, Rhizoma Pinelliae Ternatae (Ban Xia), 10g, Flos Albizziae Julibrissinis (He Huan Hua), 10g, Caulis Polygoni Multiflori (Ye Jiao Teng), 15g, and stirfried Semen Zizyphi Spinosae (Suan Zao Ren), 30g. If there was qi vacuity, Radix Astragali Membranacei (Huang Qi) and Radix Pseudostellariae Heterophyllae (Tai Zi Shen) were added. If there was torpid intake, abdominal distention, and/or loose stools, Massa Medica Fermentata (Shen Qu), Fructus Germinatus Hordei Vulgaris (Mai Ya), and sitr-fried Rhizoma Atractylodis Macrocephalae (Bai Zhu) were added. If the heart spirit was not calm, uncooked Os Draconis (Long Gu) and Concha Ostreae (Mu Li) were added. If heat was exuberant, Fructus Gardeniae Jasminoidis (Zhi Zi) and Radix Gentianae Scabrae (Long Dan Cao) were added. If blood stasis was severe, Radix Salviae Miltiorrhizae (Dan Shen), Flos Carthami Tinctorii (Hong Hua), and Hirudo Seu Whitmania (Shui Zhi) were added. If phlegm was exuberant, bile-processed Rhizoma Arisaematis (Dan Nan Xing) and Fructus Trichosanthis Kirlowii (Gua Lou) were added. If kidney essence was insufficient, Fructus Lycii Chinensis (Gou Qi Zi) and processed Radix Polygoni Multiflori (He Shou Wu) were added. These medicinals were decocted in 300ml of water down to 100ml. They were then decocted again down to 100ml. These two decoctions were then added together and administered in divided doses morning and evening. One packet was administered per day, and 30 days equaled one course of treatment, with two courses of treatment given.
Members of the comparison group received 20 milligrams of American-made Prozac once per day for 60 days.
Treatment outcomes
Marked effect was defined as a reduction to seven points in Hamilton Depression Rating Scale plus disappearance or marked improvement in symptoms. Some effect was defined as a reduction of 8-10 points and improvement in symptoms. No effect meant that the Hamilton Depression Rating score was still 18 points or higher. Based on these criteria, 21 out of 30 patients (70%) in the treatment group got a marked effect, five others (16.90%) got some effect, and four (13.00%) got no effect, for a total effectiveness rate of 80.90%. In the comparison group, 14 cases (50.00%) got a marked effect, five (16.42%) got some effect, and three (10.71%) got no effect, for a total effectiveness rate of 66.42%. Therefore, the Chinese medical protocol was more effective overall than the Western medical protocol.
Discussion
According to the Chinese author, Dr. Wang, post-stroke depression is due to emotional dis-ease which results in the liver's loss of spreading freely and the qi's subsequent loss of coursing and discharge. Hence there is liver depression and qi stagnation which leads to blood stasis. If the liver qi counterflows horizontally to assail the stomach, there is stomach loss of harmony and downbearing. If the liver qi attacks the spleen, there is spleen loss of fortification and movement with accumulation of dampness and engenderment of phlegm. In that case, phlegm and stasis doubly obstruct the qi mechanism which only reinforces the qi depression not flowing smoothly. Liver depression represses the spleen and this consumes and damages the heart qi. Likewise, the constructive and blood are gradually consumed. Hence the heart loses its nourishment, the spirit loses its treasuring, and the heart spirit becomes disquieted. All this leads to the appearance of a depressed mood, diminished speech, insomnia, easy waking, and poor appetite.
According to Dr. Wang, in such cases, treatment should be directed at the root, based on the saying from the Su Wen (Simple Questions), "[For] wood depression, out-thrust." Similarly it is said: Although there are many depression diseases, they are all caused by the qi not regularly flowing. Therefore, the method must be to first normalize the flow of qi.
Therefore, Dr. Wang believes that the main treatment principles or methods should be to course the liver and resolve depression aided by quickening the blood, transforming phlegm, and calming the spirit. Within this formula, Chai Hu, Bai Shao, Zhi Ke, and Xiang Fu course the liver and rectify the qi. Yu Jin and Chuan Xiong move the qi, quicken the blood, and transform stasis. Ju Hong, Ban Xia, and Fu Ling dispel dampness and transform phlegm. He Huan Hua, Ye Jiao Teng, and Suan Zao Ren nourish the blood, resolve depression, and quiet the spirit. Taken as a whole, this formula thus has the ability to course the liver and rectify the qi, transform stasis, resolve depression, and quiet the spirit.
For more information on the Chinese medical treatment of depression, see Bob Flaws and James Lake's Chinese Medical Psychiatry available from Blue Poppy Press.
Keywords: Chinese medicine, Chinese herbal medicine, psychiatry, depression, Prozac
Copyright [c] Blue Poppy Press, 2004. All rights reserved.
c/o Blue Poppy Press * 5441 Western Ave. #2 * Boulder, Colorado 80301 USA www.bluepoppy.com
abstracted & translated by Bob Flaws, Dipl. Ac & CH, FNAAOM, FRCHM
COPYRIGHT 2004 The Townsend Letter Group
COPYRIGHT 2004 Gale Group
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