Over 28 million Americans (Textbook of Natural Medicine, p. 1040) take antidepressant and anti-anxiety agents. 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 has had a major depressive episode in their lifetimes (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 perspective, 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, while antibiotic therapy does. Other emotional problems that are frequently misdiagnosed include hyperactivity caused by low-level carbon monoxide toxicity, conduct disorder due to asymptomatic 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 symptoms, rather than being carefully diagnosed to ascertain the root cause.

Chinese medicine practitioners can learn a valuable lesson from this. When diagnosing a patient, you do so through the four examination 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 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. Practitioners should be aware of this and make every effort to work with patients who are taking such medications.

Biomedical Perspective of Depression

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 may 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.

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. 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 a somatic illness, the depression can be concomitantly resolved.

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 shining 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 U.S. 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 and Depression

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 un-treated causes further disharmonies depending on the affected organ(s)

In terms of the Western concept of depression, among the seven emotions the three that are most similar in symptomatology 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.

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.

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 multi-pronged 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 be dependent on antidepressant agents.

Herbal treatment

Empirical herbal formulas used in the treatment of depression often include Polygala (yuan zhi), which is used to quiet the heart. The inclusion of this herb has been traditionally used for insomnia, palpitations and restlessness. In addition, herbal antidepressants Albizzia (he huan pi) and Western Vervain have been used for several hundred years to soothe the emotions. Other useful herbs include: Uncaria (gou teng), Gardenia (zhi zi), Damiana (folium turnerae aphrodisiaciae), White Paeonia (bai shao), Tang-Kuei (dang gui), Pinellia (ban xia), Poria (fu ling), and Aquilaria (chen xiang), which are used to 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.

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 Oyster Shell (mu li) help calm the liver. Empirically these herbs are used for anxiety states and insomnia. Also present in this formula is Bupleurum (chai hu), which invigorates liver qi. The remaining herbs, Ginseng (ren shen), Ginger (gan jiang), Pinellia (ban xia), Scute (huang qin), Cinnamon (gui zhi), Rhubarb (da huang) and 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.

Ding xin wan 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. Poria Cocos (fu shen) is especially known for its spirit quieting effects. In addition the formula contains White Peony (bai shao), Tang-Kuei (dang gui), Polygala (yuan zhi), Ziziphus (suan zao ren), Ophiopogon (mai men dong), Codonopsis (dang shen), and Amber (hu po). The pulse may be fast, and the tongue dry.

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 Fruit (Long yah rou) and Ziziphus (suan zao ren) are specific ingredients that have calming effects. The remaining herbs, Poria (fu ling), Atractylodes (bai zhu), Tang-Kuei (dang gui), Salvia (dan shen), Amber (hu po), Polygala (yuan zhi), Saussurea (mu xiang), Ginger (gan jiang),Licorice (gan cao) and Amomum (sha ren), are for dampness, qi stagnation, blood stagnation, and blood deficiency. The pulse would be thin and weak, and the tongue pale.

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 in conjunction 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's goals for herbal therapy were to minimize his medication, reduce headaches, and relieve chronic pain. Chai hu long gu mu li tang, 3 tablets QID was suggested, to relieve liver qi stagnation and to treat headache, shoulder and neck pain; and gui pi tang, 3 tablets QID, to nourish blood and treat anxiety and insomnia from qi and blood deficiency. He was instructed to take herbs and drug two hours apart. After two weeks Gus saw a slight lessening of his insomnia and headaches. As he reduced his Percodan dosage 50 percent he also noticed his mind felt clearer. Gus maintained the above mentioned herb recommendations for three months. He was able to reduce his Percodan dosage ninety-percent and he was able to 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.

Allen started on Astragalus (huang qi) and Semen Astragali Complanati (sha yuan ji li), Ligustrum (nu zhen zi), Ho-shou-wuh (he shou wu), Lycium fruit (gou qi zi), Rehmannia (shu di huang), Eucommia (du zhong), Cuscuta (tu 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 Polygala (yuan zhi), Vervain (herba verbenae officinalis), Uncaria (gou teng), Gardenia (zhi zi), Albizzia Flowers (he huan hua), Damiana (folium turnerae aphrodisiaciae), White Peony (bai 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.

Allen stayed on the same protocol of herbs, taking the herbs and the antidepressant two hours apart. Gradually, he tapered down the dosage. 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 year. Tests showed the cancer was not growing.

Case 3

Ed had 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.

He started on chai hu long gu mu li tang, 3 tablets QID and 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 Ed changed to chai hu long gu mu li tang plus Corydalis (yan hu suo), Angelica (bai zhi), White Peony (bai shao), Cinnamon Twig (gui zhi), Tang-kuei (dang gui), Salvia (dan shen), Myrrh (mo yao), Frankincense (ru xiang) and 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. It was suggested that if he wanted to function more normally that these activities would be necessary, and to concentrate on pain relieving strategies. Therefore his new protocol was 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), Notopterygium (qiang huo), Tang-kuei (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, as well as Corydalis, (yan hu suo), Angelica (bai zhi), Peony (bai shao), Cinnamon (gui zhi), Tang Kuei (dang gui), Salvia (dan shen), Myrrh (mo yao), Frankincense (ru xiang), Licorice (gan cao) 2 tablets 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 his protocol changed to a more tonifying regimen, using Millia (ji xue teng), Ho-shou-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), Lotus 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 twenty-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 chai hu long gu mu li tang, 3 tablets BID, was recommended to treat her liver imbalance according to traditional Chinese medicine. Margret was instructed 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 where all considered to be due to a liver imbalance, and to effectively treat this condition time was warranted. She was advised to 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 a formula of Kava Kava (piper methysticum), Schizanda (wu wei zi), Oyster Shell (mu li), Dragon Bone (long gu) and Amber (hu po), 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 she added a 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 little other changes.

Next, she increased her dosage of chai hu long gu mu li tang to 3 tablets TID, and maintained 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, she added 1-3 tbsp. per day of freshly ground flax seeds or flaxseed oil to meals. Over the next three months Margaret 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.

It was suggested that Margret go off the chai hu long gu mu li tang and substitute a formula of Eclipta Concentrate (han lian cao), Milk Thistle (Sylibum marianum), Curcuma (yu jin), Salvia (dan shen), Lycium Fruit (gou qi zi), Ligustrum (nu zhen zi), Bupleurum (chai hu), Schizandra (wu wei zi), Tienchi Ginseng (san qi), Tang-kuei (dang gui), Plantago Seed (che qian zi) and Licorice (gan cao), however Margaret was reluctant to go off the chai hu long gu mu li tang, as it had worked so well. Therefore, she took both preparations. She took chai hu long gu mu li tang, 2 tablets TID, and the Eclipta and Milk Thistle formula mentioned above, 2 tablets TID, along with the Valerian tincture (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.

Bipolar disorder is characterized by major depression alternating with mania or 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 a liver panel revealed only slightly abnormal liver function, her symptoms, as well as her wiry pulse indicated liver imbalance according to TCM. Therefore, the herbal formulas selected, chai hu long gu mu li tang and the Eclipta and Milk Thistle formula, 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 she also did a course of ten acupuncture treatments, which helped improve her results. As she seemed responsible and was under the care of a psychiatrist, we saw no reason not to try herbs, as an adjunctive th