Definition of depression

‘Depression’ is a modern Western term which indicates a change in mood ranging from a very mild feeling of despondency to the most abject depression and despair. In mild depression the change in mood varies and is not permanent, whereas in severe depression the change in mood is fixed and persists over a period of months or years. Severe depression is also accompanied by characteristic changes in behaviour, attitude, thinking efficiency and physiological functioning. Of course, it is normal to experience a temporary feeling of depression following adverse life events such as bereavement. In distinguishing a normal reaction from pathological depression a quantitative judgement has to be made. If the precipitant seems inadequate, or the depression appears too severe or too long lasting, the condition may be regarded as abnormal. In addition, the severity and incapacity in depressive illness differ qualitatively as well as quantitatively from depressed feelings that are part of normal experiences.

Depression is twice as common in women as in men and its onset increases towards middle age. The main symptoms of depression are depressed mood, loss of interest, self-esteem or motivation, fatigue, anxiety, insomnia and loss of appetite. In very severe cases, the patient never comes out of an extremely depressed mood, is unable to experience any pleasure at any time, is in utter despair and may be suicidal. A major depressive syndrome has the following characteristics:

In addition to the above manifestations, a major depressive syndrome is also defined by the absence of the following: an organic factor, a normal reaction to bereavement, delusions or hallucinations in the absence of mood symptoms, schizophrenia, delusional disorder, psychotic disorder.¹

Diagnosis of depression

Asking patients about feelings of depression should always be part of our questions about the patient’s emotional state and it should be carried out with sensitivity and tact. In fact, some patients will not want to admit to being depressed, some will admit to being depressed but do not necessarily want to talk about it, and others may not even realize that they are in a state of depression. These patients will often complain only of physical symptoms such as extreme tiredness, lack of motivation and feeling cold, preferring not to face up to the fact that they may be depressed. In China this is more the norm than the exception as Chinese patients will seldom complain of feeling ‘depressed’ and somatization of their feelings of depression into bodily symptoms is often seen.

Signs of depression In patients who are not aware of being depressed, Chinese diagnosis often enables us to recognize the true condition of the patient’s mental–emotional state. In fact there are certain signs that point to mental depression as the root cause of the patient’s problems and these are:

The complexion of a severely depressed person will lack lustre and will tend to be greyish or greenish; the eyes will also lack sparkle (shen); the tongue has a Red tip and may have a deep Heart crack; and the voice will be low and lacking vitality.

The pulse in a depressed person varies according to whether the condition is primarily Full or Empty. In Full conditions, the pulse feels very Wiry or Wiry and Slippery, whereas in Empty conditions (especially when sadness and grief prevail) the pulse is Weak or Choppy, often Short and nearly always lacks a ‘wave’ (Sad pulse). Interestingly, very often the pulse of a depressed person may point to the true cause of the problem being repressed anger; in fact, in some cases, a depressed patient may display many signs pointing to an Empty condition (low voice, dull complexion, slow movements) while the pulse is very Wiry. This usually indicates that the patient’s depression is due to repressed anger. Vice versa, a pulse that is Choppy, Short or Sad indicates that sadness or grief is the prevalent emotion at the root of the depression.

Depression in Chinese medicine

In Chinese medicine, mental depression was called Yin Yu, which means ‘gloominess’ or ‘depression’ or, Yu Zheng, which means ‘depression pattern’. Yu has the double meaning of ‘depression’ and ‘stagnation’, which implies that, according to this theory, mental depression is always caused by a stagnation.

In fact, the ‘Simple Questions’ in Chapter 71 mentions the Five Stagnations of Wood, Fire, Earth, Metal and Water.² The ‘Essential Method of Dan Xi’ (Dan Xi Xin Fa, 1347) describes six stagnations of Qi, Blood, Dampness, Phlegm, Heat and Food. It says: ‘When Qi and Blood are harmonized, no disease arises. If they stagnate diseases arise. Many diseases are due to stagnation… stagnation makes things accumulate so that they cannot flow freely, they would like to rise but cannot, they would like to descend but cannot, they would like to transform but cannot … thus the 6 Stagnations come into being.’³

The ‘Complete Book of Jing Yue’ (Jing Yue Quan Shu, 1624) gives stagnation an emotional interpretation and talks about Six Stagnations of anger, pensiveness, worry, sadness, shock and fear. This confirms that all emotions can lead to stagnation of Qi. It says: ‘In the 6 Stagnations, stagnation is the cause of the disease. In emotional stagnation, the disease [i.e. the emotion] is the cause of the stagnation.’⁴

Patterns in depression

Chinese books normally ascribe mental depression to Liver-Qi stagnation in its various manifestations including Liver-Qi stagnation turning into Heat and Liver-Qi stagnation with Phlegm. In the later stages of mental depression, Empty patterns appear. Thus, although in Chinese medicine stagnation and depression are almost synonymous, Empty patterns may also cause depression.

In severe depression, the Liver is always involved owing to its housing the Ethereal Soul (Hun). The Ethereal Soul is responsible for our life’s dreams, plans, ideas, projects, relationship with other people, etc. The Ethereal Soul was often described as ‘the coming and going of the Mind (Shen)’: this means that the Ethereal Soul assists the Mind in giving it the capacity to have dreams, plans, ideas, projects, etc. In this sense, the Ethereal Soul gives the Mind ‘movement’, outward projection and ability to form relationships with other people, hence its ‘coming and going’ described above. On the other hand, the Mind guides and controls the Ethereal Soul and, most of all, integrates the activity of the Ethereal Soul within the overall psychic life of the person.

Thus, if the ‘movement’ of the Ethereal Soul is lacking (either through its lack of activity or through overcontrol of the Mind), the person is depressed; if the ‘movement’ of the Ethereal Soul is excessive (either through its overactivity or through lack of control by the Mind), the person may display manic behaviour (bearing in mind that the latter may vary in intensity and seriousness from full-blown bipolar disease to much less severe manifestations that are relatively common also in mentally healthy individuals).

When a person is severely depressed, the Ethereal Soul is not ‘coming and going’ enough, and therefore the person lacks dreams, has lost faith in the future, does not know which direction to take in life and has a feeling of loss, isolation and separation. From this point of view, many Liver (and other organs) patterns, and not just Liver-Qi stagnation, may cause depression. When the Ethereal Soul ‘comes and goes’ too much, the person may develop manic behaviour; in this case, the person has lots of dreams, projects and ideas but nothing comes to fruition because of the chaotic state of the Ethereal Soul and the lack of control of this by the Mind.

Figure 44.1 illustrates the two states of the Ethereal Soul: when it ‘comes and goes’ too much; and when it does not ‘come and go’ enough.

Essential to the proper movement of the Ethereal Soul is its restraint by the Mind. The Mind (Shen of the Heart) needs to restrain the Ethereal Soul (but not too much) and integrate the material coming from it into the totality of the psyche. If the Mind controls and restrains the Ethereal Soul too much, depression ensues; if the Mind fails to control and restrain the Ethereal Soul, manic behaviours may result (Fig 44.2).