Integration of Scientific Research and Chinese Medicine to treat Depression

Although acupuncture has been practiced for over 3000 years (Ulett 1992), the Western psychological and psychiatric scientific community has produced little empirical research on the efficacy of acupuncture. With the notable exception of acupuncture as a treatment for substance abuse and dependence (for reviews see Brewington et al 1994, McLellan et al 1993), there are very few well-controlled empirical studies of the efficacy of acupuncture for psychiatric disorders. The need for empirical trials is underscored by recent surveys documenting the popularity of alternative treatments for psychiatric and emotional disorders (Cassidy 1998, Eisenberg et al 1993, 1998).

This category is written in the hope of articulating how the traditional principles on which acupuncture is based can be applied to the treatment of psychiatric problems. It is written for clinical practitioners of acupuncture, for researchers, and for other healthcare providers interested in learning about the potential use of acupuncture in the area of mental health. This category is designed to provide a standardized frame-work for the assessment of depressive symptoms from the perspective of Chinese Medicine (CM) and a manualized approach to devising treatment plans that are individually tailored to address each individual’s constellation of signs and symptoms. It may be helpful to clarify that throughout this text the term standardization is used when referring to the standardization of the methodology employed in assessment and treatment design — in this case primarily the eight guiding criteria — to emphasize the selection of a specific framework. It should be differentiated-ferentiated from the current trend towards standardizing the practice of Chinese Medicine to reflect exclusively the traditional (TCM) model (Fruehauf 1999). The approach presented in this categroy is not intended to serve as the sole and definitive approach to the clinical treatment of depression with acupuncture. The field of Chinese Medicine continues to grow precisely because of the rich diversity of clinical approaches that characterize the profession. It is hoped that this category can serve as a model and offer inspiration for other acupuncture traditions; the advancement of our profession will depend on making it amenable to scientific inquiry, which has become the ‘gold standard’ for evaluating treatments and making policy decisions.

It is intended that this manual will not only facilitate research, but also open the opportunity for acupuncture practitioners to implement a manualized treatment approach in their own practice. The benefits of using such a manualized approach are many, but include: (1) greater systematic attention to detail, (2) the opportunity to implement an experimentally tested protocol in routine clinical practice, and (3) the opportunity to gather data on the effectiveness of a researched approach in the real world setting of clinical practice.

The approach taken in this manual follows from standard principles of Chinese Medicine, which are described in detail in standard texts such as The Web That Has No Weaver: Understanding Chinese Medicine (Kaptchuk 1983), The Practice of Chinese Medicine (Maciocia 1994), The Foundations of Chinese Medicine (Maciocia 1989), and A Compendium of Traditional Chinese Medicine Patterns and Treatment (Flaws & Finney 1996). The manual is designed for use with persons that meet Western criteria for major depression of less than 2 years’ duration, according to the diagnostic criteria of the Diagnostic and Statistical Manual, fourth edition (DSM-IV; American Psychiatric Association 1994).

The features of the approach in this manual should be familiar to any practitioner trained in Chinese Medicine:

n An assumption that Western-defined depression is heterogeneous and may be characterized by one or more distinct patterns of disharmony, which may differ for different clients with depression.

Differential diagnosis using signs and symptoms, client interview, taking of pulses, and an examination of the tongue, integrating five areas:

—             eight principles

—             qi, blood and body fluids

—             viscera and bowels

—             channels and network vessels

—             five phases.

Given a pattern of disharmony or combination of patterns identified through differential diagnosis, the development of specific treatment principles.The selection of points to address the treatment principles.Acute treatments delivered twice per week for 8 weeks, and once per week for 4 weeks.Maintenance and continuation treatments semimonthly and then monthly for the next year.                       •A goal of producing clinically meaningful change: improved balance rather than disharmony, remission as defined by DSM-IV criteria, and Hamilton Rating Scale for Depression (HRSD) score 6.

Moreover, this manual details assessment and treatment suitable for persons with DSM-IV-defined major depression of less than 2 years’ duration. The details of diagnosing major depression are covered in the next post. It is not necessarily the case that the framework and techniques in this manual are not useful, at least in part, for people who do not meet the restricted criteria for major depression, but the effectiveness of this treatment for conditions other than narrowly defined major depression has not been investigated systematically. More ovei although the approach has been tested with women, it is currently being tested with men. In addition, the approach remains untested with clients with comorbid disorders, dysthymia, and chronic depression. Finally, although it is the authors’ view that acupuncture can be fruit-fully combined with psychotherapy, this manual covers the use of acupuncture as the exclusive treatment, without adjunct treatments such as psychotherapy, pharmacotherapy, or herbal interventions.

This category was written, with the aim of promoting sound scientific research on acupuncture and depression, while still providing flexibility and individualization in assessment and treatment planning — a necessary feature of Chinese Medicine. The theoretical paradigms that underlie acupuncture are very different from the Western medical models. Therefore, proper research studies in this field must incorpor-ate an energetic diagnosis based on the principles of Chinese Medicine (CM) in order to identify treatment protocols correctly, rather than rely solely on Western diagnostic systems (Bensoussan 1990).

The utilization of a manualized treatment approach in clinical trials involving acupuncture provides the essential flexibility necessary to deliver individualized treatment, while conforming to the standardization fundamental to conducting sound research. The use of a treatment manual promotes the systematic articulation of the chosen framework (in this case primarily the eight principles), thus providing replicability and systematization while allowing for individualized treatment. Additionally, a manualized treatment approach increases the quality and consistency of the treatment by standardizing the technical aspects, providing a precise framework for training and supervision, enabling the evaluation of practitioner competence and conformity, and increas-ing the ability to identify the most essential therapeutic aspects of the approach. A treatment manual should not aim at limiting treatment options within a narrowly defined protocol, but rather it should provide the freedom to identify a variety of treatment possibilities within a sound conceptual framework.

According to Chinese Medicine, any piece of information (symptom or sign) gathered from the client can be interpreted only in relation to other symptoms and signs. The integration and consideration of all significant variables that relate to the process of diagnosis and treatment is paramount in Chinese Medicine. Rather than eliminate variables in order to control the treatment outcome, Chinese Medicine seeks to integrate all significant variables, in order to create the most effective treatment. A certain flexibility is needed to assess accurately the efficacy of acupuncture, precisely because the theory of acupuncture is structured around the integration of data. Nevertheless, some standardization of treatment is necessary for the purposes of replication in research and clinical practice (Bensoussan 1990).

In other words, individuals who share a Western diagnosis (e.g. depression) will be characterized by a variety of CM-based patterns of disharmony which, in turn, dictate particular treatments to address these patterns of disharmony. Treatments, therefore, must be tailored to each individual’s symptom picture; a ‘standard’ treatment must not be uniformly administered to all individuals who share a Western diagnosis. This manual describes the framework and procedures by which acupuncturists may reliably arrive at individualized diagnoses and treatment plans. In pilot work designed specifically to assess how well individuals could agree using this framework and these proce-dures, five women with major depression were seen independently by two acupuncturists within a 3-day period. Overall agreement was quite high, as indicated by an intraclass correlation coefficient1 of 0.78, summarizing their composite agreement. This result suggests that practitioners can agree on which pattern(s) of disharmony char-acterize any given individual’s depression, and agree on the treatment that should ensue.

Aside from our pilot study (Allen et al 1998), which is detailed in a future post, the only studies of acupuncture as a treatment for depression or depression-like syndromes have been published in China (Chengying 1992, Han 1986) and in Eastern Europe and the former Soviet Union (Cherkezova & Toteva 1991, Frydrychowski et al 1984, Polyakov & Dudaeva 1990, Polyakov 1987, 1988). It is difficult to evaluate these studies fully, because the diagnostic criteria used differ from those of the DSM-IV, and because most of these studies have not been translated into English (other than the abstracts). Collectively, however, these studies suggest that acupuncture may be effective in the treatment of depression and depressive symptoms, in some cases as effective as tricyclic antidepressant medication. The following review summarizes these studies, with a focus on the range of depressive symptoms for which acupuncture may and may not be effective.

Polyakov (1988) treated 167 depressed patients with acupuncture. Acupuncture reduced the principal symptoms of depression and also lessened the severity and prominence of supplementary symptoms. The best results from acupuncture were obtained in patients with melancholic depression; poor results were obtained in patients with anxious and apathetic depressions. Acupuncture was almost as effective as antidepressants in cyclothymic depressions and was notably inferior to tricyclic antidepressants in patients with psychotic features. Moreover, Polyakov (1988) reported that follow-up studies over 1-2 years indicated that adequate maintenance therapy produces results comparable to drug therapy, although inadequate information was provided to evaluate this claim. In this study, acupuncture was carried out using a standardized method of treatment that consisted of five acupuncture points located in the traditional meridians (St 36, P S, P 6, Lu 7, and LI 4) plus three ear acupuncture points (AT affect, AT Shenmen, and AT Zero). From the perspective of pattern differential diagnosis (the assessment method of Chinese Medicine), the finding of poor treatment response in anxious and apathetic depressions is not surprising, because this set of points does not specifically address the features present during anxious or apathetic depressions. This highlights the importance of considering individual differences in symptom presentation and tailoring points accordingly, as detailed in this manual.

Other studies provide only abstracts in English. Chengying (1992) used points on the Du channel (which runs along the spine) to treat a melange of psychiatric disorders including anxiety, depression, hypochondria, neurasthenia, obsessive—compulsive disorder, aphasia, alexia, and hysterical paralysis. A total of 115 patients with a course of disease from 2 months to 8 years were treated with points selected from the Du channel. Points were selected by pressing the points one by one, observing and comparing sensitivity to the points, and choosing to needle the 1-2 points with the maximum response. Of the 115 patients, 61 experienced complete disappearance of psychoneurotic and somatic symptoms and no recurrence at 6-month follow-up, 31 experienced a significant improvement, and 23 had no significant improvement after treatment. Although Chenying (1992) studied a heterogeneous group, the comparability of the diagnoses neurasthenia and major depression was noted by Chang (1984). Commenting on the observations of Dunner & Dunner (1983), Chang indicated that almost 50% of psychiatric outpatients in China are diagnosed with neurasthenia, and that many of these neurasthenics would be diagnosed by the DSM with major depression. Moreover, Chang (1984) noted that antidepressants were as effective with cases of neurasthenia diagnosed by Chinese psychiatrists as with cases of DSM-defined depression.

A further 103 patients with neurasthenia (course of disease from 3 months to 20 years, average of 4.5 years) were observed clinically at the Academy of Traditional Chinese Medicine (Suobin 1991). Principal points Du 14, Du 13, GB 20, the first line on the Bladder channel, bilateral to the spine and the Huatuo paravertebral points (M BW 35 (Jiaji); O’Connor & Bensky 1981) were used, along with other points chosen according to symptoms. Following treatment 45 patients were relieved of all their symptoms and were considered clinically cured, 29 experienced an improvement of the main symptoms but some secondary symptoms remained, 21 experienced a noticeable improvement, and eight had no improvement at all.

Another Chinese study, by Luo, Jia, and Zhan of the Institute of Mental Health, Beijing Medical College, examined electro acupuncture and amitriptyline treatment of DSM-III-defined major depression. This study, summarized by Han (1986), found comparable decreases in HRSD scores as a function of electro acupuncture and amitriptyline treatments over a 5-week interval: mean ± SD HRSD scores dropped from 28.5 ± 1.2 to 12.8 ± 2.0 for patients receiving acupuncture, and from 29.4 ± 1.4 to 14.2 ± 1.9 for those receiving amitriptyline. Moreover, fewer side effects were reported for patients receiving electroacupuncture. Unfortunately, this study used only two points (Du 20 and Yintang), and it is unclear whether standard needling, as opposed to electroacupuncture, would provide compara-ble results, although some (Ulett 1992) claim that the effect of acupuncture is due entirely to the frequency of stimulation rather than to the specific points selected. Another Chinese study (Hechun 1988; summarized by Brewington et al 1994) also found comparable decreases in depressive symptoms in patients having electroacupunc-ture and those receiving amitriptyline. Finally, acupuncture also appears to diminish depressive symptoms in the context of opiate detoxification (Cherkezova & Toteva 1991, Newmeyer et al 1984).

Although far from definitive, taken together these studies suggest that it is possible to obtain favorable results using acupuncture to treat mood-related symptoms, including depression. These findings encouraged us to undertake a pilot study to examine the efficacy of acupuncture as a treatment for depression.

Chinese Medicine Theory – The Assessment of Depression Within the Framework of Chinese Medicine

Although any acupuncturist using this manual would be knowledgeable of the basic concepts of Chinese Medicine (CM), and would probably be familiar with the eight guiding criteria as a style of treatment, a complete section on the theoretical framework is included. This has been done for the sake of continuity as well as to introduce the nonacupuncture community to the Chinese Medicine conceptualization of depression. The aim is not only to provide a clinical tool for acupuncture practitioners but also to foster understanding and collaboration between acupuncturists, psychotherapists, physicians, and researchers.

Theoretical References

In the development of our treatment protocol for depression, we sought to integrate five areas or ‘filters’ (Seem 1985) which serve as the basis for assessment and treatment in acupuncture:

1. Yin/yang and eight guiding criteria

2. Viscera and bowels

Qi, blood and body fluidsChannels and network vesselsFive phases.

The pilot study outlined in a future post, as well the framework for this manual, are based primarily on the first three filters: (1) the eight guiding criteria, (2) viscera and bowels, and (3) qi, blood, and body fluids. These three filters are generally used together as a unit. Although the different theories that serve as the foundation for the five areas can be artificially compartmentalized, in reality they function together as a whole, and are all necessary to understand the etiology and progression of imbalances. The approach presented in this manual aims to integrate what we have found to be the most useful features of each ‘filter’ in the evaluation and treatment of depression, while emphasizing the use of the eight guiding criteria, viscera and bowels, and qi, blood and body fluids, as the foundation for treatment design. All five areas mentioned above are used in some way to explain the disease mechanisms that underlie depression, to understand the pattern differentiation characteristic of depressive episodes, and to outline the treatment principles and treatment strategies for point selection. We use the step-by-step methodology characteristic of eight principles pattern identification: (1) differentiate signs and symptoms using the four evaluations, (2) establish disease mechanisms, patterns, and pattern combinations, (3) outline treatment principles, and (4) design a treatment plan. We have, however, deviated from what is commonly known as traditional Chinese Medicine (TCM) in essentially three ways: first, we make extensive use of the five-phase theory in the initial interview to determine the specific nature of each person’s experience of depression; second, we encourage palpation of the abdominal area, and the channels for point selection; and third, we modify our point selection and total strategy over time, on the basis of channel interactions that are not emphasized in TCM. Such channel interactions are more broadly used by the Vietnamese and French acupuncture schools, some Japanese acupuncture styles, and the acupuncture style developed by Dr Mark Seem.

After having used this manual extensively, as both a clinical and a teaching tool, it became obvious that the treatment strategies that had been used consistently as part of our treatment protocol expanded the framework beyond the TCM model. The rationale for point selection, point combinations, and point location, although based on TCM (‘TCM is a style of Chinese Medicine that emerged predominantly from the People’s Republic of China in the twentieth century, and which is presented as the standard model of Chinese Medicine in mainland China today. For an interesting discussion of TCM, its history, development, and clinical standards, see Fruehauf (1999).) pattern differentiation, was heavily influenced by training under Mark Seem. Seem’s approach developed through the influence of the French energetic school of acupuncture, and the work of Dr Van Ghi. For this reason, the section that describes the channels and network vessels deviates from standard TCM theory to include a broader consideration of the complexity of the channel system, which has very little importance in TCM as a style of treatment today. Although purists in any of these traditions may argue against combining different styles of treatment, in reality the contemporary practice of acupuncture has emerged as a ‘weaving of lineages within the diverse traditions that make up Oriental medicine’ (Hougham 2000). In line with this view, the authors hope to make a small contribution towards the development of a foundation for a multidimensional energetic approach to the assessment and treatment of depression — one that allows the practitioner to stratify treatment options based on an integrated use of the five filters. It needs to be emphasized, however, that any system that may emerge from this endeavor — to be authentic and internally coherent — must develop on a solid foundation: one that is based on a clearly articulated theoretical framework and a consistent treatment methodology.

The authors recognize the validity and significance of diverse schools of thought in the treatment of depression with acupuncture. We selected the eight guiding criteria as the primary framework for our study because in our view: (1) the eight criteria offer a methodological approach that can be more easily replicated in control studies, (2) most of the existing research literature for acupuncture in the treatment of depression uses the eight guiding criteria directly or indirectly, (3) the reference literature available in English is based on these criteria, and (4) the eight guiding criteria as a style of treatment offers more consistent treatment protocols. It is of great interest to the authors to be able to compare — in the future — different styles of treatment and their clinical outcomes, but this was not an aim of our pilot study, nor of this category.

In order to establish a parallel between Western-defined major depression and acupuncture patterns of disharmony, we looked at depression as a complex interplay of disease mechanisms that develop from three main factors: (1) the patient’s predisposing tendency towards vacuity or repletion of either yin or yang, (2) the liver’s inability to maintain the free and smooth flow of qi, and (3) a disturbance in the heart’s function of housing the spirit (shen).

In this way, the question we pose within the context of Chinese Medicine is not only whether someone is depressed, but how this person is experiencing depression, and what precipitating factors — physical, psychological, and social — have contributed to his or her present condition. Chinese Medicine offers, then, a framework for understanding distinct symptom pictures and for developing a treatment approach based on the nature of each individual’s particular symptom pattern. Thus acupuncture treatments focus on the entire symptom picture, which includes physiological as well as psychiatric symptoms.

Chinese philosophy is based on the premise that all life occurs within a unified system, that all phenomena are manifestations of a unifying principle of energy or life force, and that all manifestations of life are connected and mutually dependent upon one another. Life unfolds as a process of differentiation that expresses the interaction between two complementary forces, yin and yang, which represent the totality of the dynamic equilibrium. This unified system is understood as a process of fluctuations and permanent change, as the cyclic nature of continuous movement. Everything can be characterized as either yin or yang, relative aspects of an alternating cycle along a single continuum (Beinfield & Korngold 1991). The creative principle that symbolizes life in all its forms and which activates every process that characterizes living entities is known as qi (pronounced `chee’) or `vital energy’, and is central to Chinese medical theory.

Human beings are considered a microcosm that reflects the universe that surrounds them — a dynamic series of energetic fluctuations constitutes the body as a living system (Seem 1987). Each of us is an ecosystem living within a larger ecosystem. The balance of forces within us determines our health and disease (Beinfield & Korngold 1991).

Acupuncture looks for disharmonies of qi and, strictly speaking, depression does not exist as a disease category in Chinese Medicine. When an acupuncturist using the eight-principles framework is asked to evaluate a ‘depressed’ person, he or she weaves all relevant information into a pattern of disharmony, a description of the dynamics that portray a situation of an imbalance. Symptoms are part of this imbalance which can be seen in other aspects of the patient’s life and behavior (Kaptchuck 1983). Because the patient is always considered as a body—mind continuum, somatic and psychological symptoms are equally important.

By focusing on the detection of qi imbalances, rather than on the diagnosis and treatment of disease, Chinese Medicine explains relation-ships between physiological and psychological events that are considered separate phenomena in the Western medical model. Chinese Medicine offers a physiology that postulates a clear connection between somatic events and psychological concepts of mind and emotion, helping to close the gap between soma and psyche (Seem 1987). As with any other diagnostic system, the theoretical framework provided by Chinese Medicine can be used to understand the appearance of symptoms that characterize depression, to account for the heterogeneity of symptom presentation in depression, and to devise individually-tailored treatments for particular constellations of depressive symptoms.

Chinese Medicine defines health as the balance between yin and yang, which depends on the capacity of an organism to adapt to change and maintain equilibrium. Sickness is the result of vacuity or repletion of either yin or yang. Vacuity is defined as: weakness of the forces (right qi) that maintain the health of the body and fight disease, an insufficiency of vital substances (yin, blood, body fluids, essence; i.e. yin humor), or the diminished capacity of physiological processes. Repletion is defined as: an accumulation of physiological products (phlegm, dampness, blood, and qi) that are harmful to the body and may obstruct functioning, or as the relative excess of either endogenous or exogenous pathogens (in Chinese Medicine endogenous or exogenous pathogens are known as ‘evil qi’ (xie). They include the six qi (wind, cold, fire, summerheat, dampness, and dryness) in their capacity to cause disease; the ‘warm evils’ (warm heat school), and various types of toxins. Additional pathogens are wind, cold, fire, dampness and dryness arising within the body, and static blood and phlegm produced by the body (Wiseman & Feng 1998).) that may threaten the health of the organism. Vacuity and repletion are both imbalances between yin and yang.

The homeostasis of an organism — the balance between yin and yang — is sustained by the proper circulation of qi along energetic pathways or meridians, commonly known as the channels and network vessels. The channels form a network that connects the surface of the body with the internal organs (viscera and bowels), serving as a two-way communication system, which both conveys messages to the surface about internal malfunctioning and alerts the internal functions about surface phenomena that might be threatening to move deeper into the system (Seem 1987). The channels and network vessels are the surface manifestations of the viscera and bowels, and act as an irrigation system that regulates the supply of qi and prevents accumulations. The internal organs in Chinese Medicine are defined by their functions and interrelations, rather than by their somatic structures or specific anatomic locations. They work as spheres of influence, and represent a complete set of functions that reflect energetic relationships among physiological and psychological events. In order not to confuse them with the biomedical entities of the same name, we refer to them as viscera (yin) and bowels (yang); they are also sometimes referred to as organic—energetic functional units, organ functions (Seem 1987), organ networks (Beinfield & Korngold 1991), or energetic orbs (Porkert 1983). There are five viscera and six bowels. The viscera and bowels and the channels both work in pairs, with one yin and one yang function interconnected:3 lung—large intestine, stomach—spleen, heart—small intestine, kidney—bladder, pericardium—triple heater, liver—gall bladder, yin and yang respectively.

The Chinese characters for yin and yang denote the sunny and shady sides of a mountain respectively. These two complementary and opposing principles are used to describe phenomena that have a similar quality and relationship, including the different functions and parts of the body. Yin and yang are rooted in each other: they are interdependent, relative to one another, divisible but inseparable. Yin and Yang counterbalance and complement each other and transform into each other.

The pericardium is considered as an extension of the functions of the heart and it is said to act as a buffer that protects the heart from external influences; it is not considered a separate viscera. In the context of the channels and network vessels, the pericardium is a channel in its own right and is considered the yin pair of the triple heater channel. Therefore, there are five (yin) viscera and six (yang) bowels; but there are six yin and six yang channels or meridians.

The potential for differentiation into yin and yang (earlier heaven), upon which life depends, is received from our parents at conception and stored in the kidney. The kidney has a very special relationship with the other viscera and bowels because it holds the foundation for their own yin and yang (Kaptchuk 1983). Each of the other viscera and bowels is considered to have a yin (storing, nour-ishing, cooling) component and a yang (activating, protective, warming) component, which are said to stem from the yin and yang roots of the kidney, respectively (Seem 1987). According to Kaptchuck (1983), yin is what sustains and conserves the organism and grants us the qualities of rest, tranquility, and quiescence; yin condenses and concentrates inwardly the energy of life. Yin moistens, softens, stabilizes, and roots life, and grants us the capacity to unfold gracefully while being content, quiet, and present. When yin is insufficient, we lack the qualities of receptivity and contemplation and become easily agitated, unsettled or nervously uneasy; the control over the dynamic manifestations of heat and activity is lost (Kaptchuk 1987). Yin represents the latent potential that awaits to be expressed and organized (Seem 1987).

Yang, by contrast, causes transformation and change, providing us with the capacity to engage life, to react, and to respond. Yang expands and disperses outwardly, granting the basic animating and invigorating quality of life that expresses our capacity to move, activ-ate, and transform. When yang is insufficient, we find ourselves para-lyzed in fear, confused and indecisive, unable to &press what we want, hopeless. When the quickening power to move is lost, the expression of life becomes soggy, congested, inactive, and frozen (Kaptchuk 1987).

Usually, we can detect in every person a relative vacuity of either the yin or yang roots of the kidney, which will affect in turn the rela-tive vacuity or repletion (hypoactivity or hyperactivity) of the associ-ated yin or yang viscera and bowels (Seem 1987). These tendencies, which can be both trait and circumstantial, will influence the manner in which an individual responds to his or her environment and the stressors therein.

When considering the human being as a smaller system living within a larger system, individuals’ relationships to their environ-ment become of the utmost importance in the development of illness. Each of us will experience an event and react to a stressor in a dif-ferent way. Our predisposition to develop a disorder at any given time depends on our individual experience of being in the world. Situations that create a conflict between our internal needs and desires and the demands placed upon us precipitate personal patterns of reaction based on our relative vacuity or repletion of either yin or yang (Seem 1987).

Based on this model, major depression can be considered as a `somatic energetic reaction pattern’ that is fueled by psychological and physical energies that are unique to the individual and that affect the experience of the disorder and nature of the symptoms. Moreover, this somatic energetic reaction pattern will influence the treatment protocol and prognosis. Stated differently, although persons with major depres-sion may share common symptoms, for each individual the dynamics of dysfunction would have developed in such a way that will require indi-vidualized treatment based on differential energetic diagnosis.

Fundamental Substances: Qi, Blood, Essence, Spirit, and Body Fluids

Qi

things; all physical and mental activities are manifestations of qi, and qi is perceived functionally by what it does (Beinfield & Korngold 1991). Sometimes referred to as ‘vital energy’ or simply ‘energy’, the concept of qi is much broader: qi is what motivates all movement, transformation, and change. According to Chinese Medicine, qi has five functions: defense, transformation, warming, restraint, and trans-portation. Qi protects the exterior of the body from invasion by exter-nal pathogens; it transforms substances so that they can be used by the organism; it provides warmth for the entire body; it holds the organs and substances in their proper place; and it propels all movement and transportation in the body.

Blood

According to Chinese Medicine blood is the substance that nourishes and moistens our body tissues. Blood is derived from food by the stomach and spleen, it is governed by the heart, stored in the liver, and moved through the vessels by the combined action of the heart and lung. When the blood is scanty or insufficient, no functions can take place; the blood moistens all body tissues, including the ligaments and tendons known as sinews in Chinese Medicine, as well as the skin and the eyes. Without proper nourishment and moisture, the tissues of the body can stiffen, dry out, and wither.

Blood and qi are very closely interrelated. In the human body, qi is the yang in relation to blood, which is the yin. The qi moves the blood, and the blood provides the material foundation for the qi. Blood, being yin in nature, provides nourishment and moistening, as well as the material foundation for the shen or spirit, which is yang. By accumulating in the heart, the blood helps to house and anchor the shen, and keep it rooted in the body (Schnyer & Flaws 1998). Later on, we will look in detail at some of the mental and emotional symptoms experienced during depres-sive episodes, which result from insufficiency or stagnation of blood.

Spirit

The Chinese concept of shen, or spirit, corresponds to the mental capac-ity to think, feel, and respond; it is what allows us to be conscious and alert during the day, and what becomes inactive during sleep. In that sense, shen refers to the Western concept of ‘mind’ (Wiseman & Feng 1998). In Chinese Medicine shen represents the accumulation of qi and blood in the heart; sufficient qi and blood accumulating in the heart are necessary to give rise to consciousness or spirit (Schnyer & Flaws 1998). Because shen is considered to have a material basis, its importance in medicine is not independent of the body. Kaptchuk (1983) refers to shen as the capacity of the mind to form ideas and the desire of the person-ality to live life. Human consciousness, memory, mental and emotional faculties, and awareness all indicate the presence of shen. For there to be consciousness and awareness, there needs to be sufficient qi; for the spirit to be quiet and calm, there needs to be enough blood to nourish it and settle it. Without sufficient blood (yin), the shen or spirit (yang) becomes restless; without enough qi our mental clarity is impeded (Schnyer & Flaws 1998).

Essence

Essence is the most fundamental, essential material the body utilizes for its growth, maturation, and reproduction (Schnyer & Flaws 1998). Essence determines the strength of the constitution. In women, the outward manifestation of essence is blood; in men it is semen. There are two forms of this essence: inherited essence, which is the constitutional basis acquired from our parents, and acquired essence, derived from the food and liquids we consume and the air we breathe. The natural process of living is the way in which we utilize this essence; we come to the world with a limited supply of inherited essence, our lifestyle choices determine the rate with which we use up this supply. Because all body functions depend on this essence, and because inherited essence cannot be replaced, it is very important to conserve it.

According to Chinese Medicine our inherited essence is a reservoir, and it is the acquired essence we create by eating, drinking, and breathing that provides the foundation for the qi and blood we utilize for our daily activities. If we eat properly, and through digestion we transform food and drink efficiently into nourishment (qi and blood), we produce sufficient qi and blood to perform our day-to-day activi-ties. If, in addition, we have a good night’s sleep, any surplus of qi and blood that was not utilized during the day goes on to bolster our inherited essence and become part of our reservoir (Schnyer & Flaws 1998). Inherited essence is governed and stored by the kidney; acquired essence is governed by the spleen.

This is, in part, the reason why digestion and diet are instrumental in understanding the mechanisms that underlie chronic and recurrent depression, why depression is more prevalent in women than in men (Kessler et al 1994), and why aging may be a risk factor in depression (Beekman et al 1999).

Body Fluids

The concept of body fluids comprises all the normal fluid substances of the human body; this term refers to fluids actually flowing within the human body, and to sweat, saliva, stomach juices, urine, and other fluids secreted or discharged by the body (Wiseman & Feng 1998). The body fluids are therefore different to the previous four concepts, as these fluids are the same as would be described in Western medicine. Body fluids in Chinese Medicine are differentiated as liquid fluids, which are thinner, mobile, and relatively yang in quality, and humor, which are thicker, less mobile, more turbid, yin fluids. The main function of the fluids is to keep the viscera and bowels, the skin, the hair, and the body orifices moistened; addition-ally, they lubricate the joints and nourish the brain, marrow and bones (Wiseman & Feng 1998).

The formation, distribution, and discharge of fluids involve complex processes in which several viscera and bowels play important roles. The processing of fluids begins in the stomach, where the useful part of the fluids (essential qi) is absorbed. The spleen carries this essential qi to the lungs, from where it is distributed to the other parts of the body. The small intestine separates the clear from the turbid, whereas the large intestine further absorbs fluid while conveying the waste material downward. Finally, the kidney plays the most impor-tant role in the formation and replacement of fluids by providing the warming and activating force for the other viscera and bowels to perform their roles; in addition, the kidney is responsible for trans-forming the surplus and waste fluid into urine, to be later discharged by the bladder.

The relationship between the concepts of viscera and bowels in Chinese Medicine and the organs as we know them in Western medicine is mostly of name and not of function. As mentioned above, the organs of Chinese Medicine represent a complete set of functions, both psychological and physiological, and are defined by their inter-action rather than by their anatomic structure. Each viscus and bowel has a responsibility for maintaining the physical and mental health of the organism. The viscera (relatively yin organs) store the essence and are responsible for creating and transforming qi and blood; the bowels (relatively yang organs) decompose food and convey waste. As mentioned above, there are five viscera — liver, heart, spleen, lung, and kidney (the pericardium is considered a sixth viscus in channel theory) — and six bowels: gall bladder, small intestine, stomach, large intestine, urinary bladder, and triple heater. The viscera and bowels are paired by functional relationship, respectively.

`The Liver holds the office of General of the armed forces. Assessment of circumstances and conception of plans stem from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallée 1985, p. 34)

The liver controls ‘coursing and discharge’, meaning that it regulates the smooth and unobstructed flow of qi and blood. The liver maintains the uninhibited and free movement of qi throughout the body in order to prevent stagnation.

According to Hammer (1990), the liver is the first line of emotional defense for the entire organism; when confronted by a noxious emotional stimulus, this energy system is the organism’s first choice for coping with the stressor. The liver deals with the stressors by assuring constant movement and circulation of qi, thus preventing stagnation.

The liver network expresses the capacity for growth, development, expression and change. Any experience that would inhibit this potential would directly affect the ability of the liver to maintain free flow. Any intense emotion that would find no release through verbal expression or physical activity would increase the demand on the nervous system for qi and blood, and would potentially render the liver incapable of renewing and circulating noxious energy (Hammer 1990). A condition of blockage or stagnation of qi would set in. Emotions, and especially anger and frustration, are the primary causes of liver qi stagnation.

Liver qi stagnation affects, in turn, other functions of the liver such as storing the blood and regulating digestion. It may also manifest as a blockage along the pathway of the liver channel (which traverses the pelvis, abdomen, chest, throat, gingiva, and head). Depending on the viability of the organ systems in a particular individual, liver depression qi stagnation may affect the functions of other viscera and bowels. The combination of liver depression with predisposing factors precipitates, in turn, the cascade of disease mechanisms that characterizes each distinct pattern of disharmony present during depression. We will explain further the concept of qi stagnation, its relationship to depression, its complications and ramifications.

Because the first effect of the emotions as causative factors of disease is to upset the liver’s function of coursing and discharge (i.e. the movement and transformation of qi and its proper circulation and direction), liver depression qi stagnation is likely to always be a significant factor in mental—emotional problems.

The term ‘liver depression qi stagnation’ is a technical one used in Chinese Medicine to denote a particular disease mechanism and pattern of disharmony that involves the liver and that implies qi stagnation due to emotional stress and frustration (Wiseman & Feng 1998).

`The Heart holds the office of Lord and Sovereign. The radiance of the spirits stems from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 23)

The heart is considered to be the emperor of the bodymind, the gov-ernor of the five viscera and the six bowels. The heart stores the shen or spirit, and is therefore considered to be the seat of consciousness and mental functions. If the heart is working normally, and qi and blood are abundant, the mind is lucid, alert, and responsive to the environment (Wiseman & Feng 1998 ).

Mental illnesses and emotional disorders in general affect the heart, but rather than originating in the heart itself, damage by the emotions begins in some other viscus or bowel eventually affecting the heart (Schnyer & Flaws 1998). All emotions affect the heart besides affecting their corresponding viscus or bowel (Maciocia 1994). Many of the symptoms characteristic of mental and emotional imbalance, such as sleep disturbances, incoherent speech, confusion and disorientation, anxiety and palpitations, correspond to an inability of the heart to perform the function of housing the shen. The heart’s ability to house the spirit can be affected by disease mechanisms that precipitate either vacuity or repletion patterns. When we refer throughout this manual to the concept of shen disturbance, we are referring to the different patterns that affect the heart’s function of housing the shen or spirit.

`The Spleen and Stomach are responsible for the storehouses and granaries. The five Wei (tastes) stem from them.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 64)

The spleen assimilates nutrients from food in the stomach to make qi, blood, and fluids; it governs the movement and transformation of food and water and the distribution of its essence (nutrients), playing a very important role in the creation of qi and blood. In Chinese Medicine it is said that the spleen is the source of qi and blood formation (Wiseman & Feng 1998), the source of engenderment and transformation (Schnyer & Flaws 1998). On the one hand, if the spleen becomes diseased it may not be able to create and transform sufficient qi and blood to nurture the heart and to provide mental clarity and awareness. On the other hand, if it fails in its function of moving and transforming body fluids, dampness may accumulate and lead to phlegm. Phlegm in Chinese Medicine denotes a viscous (yin) fluid that, when accumulated, may cause disease anywhere in the body; it may create a disturbance of the heart spirit and affect mental functions characterized by confused thinking, dullness of thought, brooding, and rumination.

`The Lung holds the office of Minister and Chancellor. The regulation of the life-giving network stems from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 30)

The lung is responsible for breathing and the production of qi; it moves and circulates the qi out to the edges of the body and from the top downwards. It assists the metabolism of body fluids by carrying water downwards to the bladder and preventing the accumulation of water in the body. In addition, the lung helps to protect the body from invasion by external pathogens. Like the heart, the lung is often affected by disease processes initiated in other viscera and bowels. For example, when liver qi stagnation affects the lung, it may create a sense of constriction in the chest, breathlessness, and a tendency to weep.

`The Kidneys are responsible for the creation of power. Skill and ability stem from them.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 76)

As we saw previously, the kidney as a single functional unit provides the basis for our congenital constitution; it stores the essence and holds the foundation for the yin and yang of all other viscera and bowels. The essential qi of the kidney is responsible not only for our reproductive capacity but also for the growth, development, and aging of the body (Wiseman & Feng 1998). In addition, any enduring disease damages the kidney, including mental and emotional problems. The harmonious relationship between the kidney and the heart is fundamental for the physical and mental wellbeing of the organism; these two viscera are interdependent and counterbalance each other. The kidney is the seat of the essence (jing), while the heart is the abode of the spirit (shen). Jing and shen, essence and spirit, soma and psyche, are aspects of a continuous process. Shen refers to the organizing force of the self, whereas jing refers to the material substance; together they refer to the totality of the human being (Beinfield & Korngold 1991).

`The Gall Bladder is responsible for what is just and exact. Determination and decision stem from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallée 1985, p. 43)

The main functions of the gall bladder are to secrete bile, which is formed from an excess of liver qi, and to govern decision. This last function implies that the capacity to maintain a balanced judgement in the face of adversity is attributed to this bowel; strong gall bladder qi ensures less vulnerability to external stimuli (Wiseman & Feng 1998), greater courage, and less timidity.

The gall bladder, however, plays a very important and somewhat peculiar role in the clinical treatment of mental—emotional disorders. This role is based on the relationship that the gall bladder has to the heart on the one hand, and to the liver on the other. The 11 organs are said to depend on the gall bladder and, therefore, if the qi of the gall bladder is strong, endogenous or exogenous pathogens cannot enter. These two statements link the gall bladder to the heart and its spirit, and elevate it to a place of greater importance (Schnyer Flaws 1998). The relationship between the heart and the gall bladder is further emphasized by a Chinese Medicine theory known as the `midday—midnight law’. This theory states that the circulation of qi along the channels is said to take its course over a period of 24 hours; according to this theory there is a special clinical relationship between viscera and bowels, which receive their maximal flow at opposite times of the day (Mann 1973). The heart has its maximal activity at 12 noon, while the gall bladder has its maximum activity at 12 mid-night.’ If the gall bladder is stimulated through acupuncture, the heart will be stimulated as well. It is interesting to note in this regard that several acupuncture points located on the gall bladder channel have a very profound effect on the treatment of mental—emotional conditions. Furthermore, the gall bladder is considered ‘the official residence of clear fluids’ (Flaws 1994) and it influences the transformation of body fluids. Therefore, points along the gall bladder channel are very effective in the treatment of patterns that involve accumulation of dampness and phlegm obstructing mental clarity, which are frequently found in depression. It is also worth mentioning that the guiding herbal prescription traditionally used to treat these type of patterns (phlegm dampness, obstruction, and stagnation, phlegm confounding the orifices of the heart, heart vacuity—gall bladder timidity, and phlegm fire harassing the heart) is known as `warm the gall bladder decoction’ (wen dan tang).

Also, the gall bladder stands as the yang counterpart of the liver. When qi (which is yang) accumulates, it becomes hot and tends to move in a yang direction: upwards. Therefore, stagnant liver qi com-monly moves into its paired yang channel, the gall bladder; symptoms of liver depression qi stagnation commonly appear along the course of the gall bladder channel as fullness, distension and lack of free flow (Schnyer & Flaws 1998 ).

Stomach

The stomach is the first to receive foods and liquids into the body; it is in the stomach that foods and liquids are first collected and are broken down to allow their nutrients to be absorbed. In complementary opposition to the spleen, which extracts the nutrients from food and sends them up to the lungs to be distributed, the stomach sends the food down to the intestines to be further absorbed and eliminated. In Chinese Medicine it is said that the spleen upbears the clear and the stomach downbears the turbid to explain this complementary relationship. Together with the spleen, the stomach has a pivotal role in the creation of qi and blood; many of the disease mechanisms respon-sible for depression due to insufficiency of qi and blood are a result of disturbance in the functions of both the stomach and the spleen. In repletion patterns it is very common to find stagnant liver qi attacking the stomach and upsetting its downbearing function, and for liver heat to collect in the stomach. Liver depression qi stagnation can render both the stomach and the spleen incapable of performing their respective functions. On the one hand the stomach becomes ‘dry and hot’ and cannot downbear the,turbid, while the spleen becomes ‘damp and weak’ and cannot upbear the clear. In addition, because the heart is said to be located above the stomach in Chinese Medicine and, because heat tends to rise, stomach heat counterflows upwards and agitates the heart (Schnyer & Flaws 1998).

Functions of the Viscera and Bowels and their Role in Depression

Depression, as well as any other mood disorder, can be a manifes-tation of an imbalance in certain functions of the viscera and bowels. Emotions are considered to be manifestations of qi that, if not expressed or transformed, become stagnant; they become a cause of disease only when they are experienced excessively or for a prolonged period of time, or both (Maciocia 1994). When the qi does not circulate properly, it becomes noxious and generates an imbalance.

Chinese Medicine does not separate physiological and psychological events; the shen or spirit is made by both qi and blood, which in turn are generated by the viscera and bowels. At the same time, the functions of the viscera and bowels, our qi, and our spirit are affected by external circumstances. In Schnyer & Flaws (1998), Bob Flaws explains it in this way: ‘the mind arises as a function of the viscera and bowels, but the functioning of the viscera and bowels is affected by the experiences of the mind and the emotions’ (p. 15). He goes on to say: ‘every thought or felt emotion is nothing other than the experience of the movement of qi … [C]hanging the way the qi moves, one changes one’s mental—emotional experience, while changing one’s mind and emotions changes the way the qi moves’ (p. 15).

The lung, spleen, and kidney (particularly the yang aspect of the kidney) are the viscera more directly involved in the production and transformation of our qi; the quality and quantity of qi depends on their functions. Therefore these viscera are most likely involved in patterns of depression due to vacuity of qi/yang or accumulation of dampness and phlegm. Owing to the role the liver plays in maintaining the free movement of qi (and blood), it will likely be involved in patterns resulting from qi stagnation, although the stag-nation may also directly affect the heart and lungs. The surplus of qi generated by liver depression qi stagnation can, over time, when severe or when combined with predisposing factors, create a predominance of yang (heat or fire). Yang repletion may accumulate in the liver, the heart or the stomach, and it may also consume yin, primarily of the liver, the kidney, and the heart. Liver depression qi stagnation may also progress into blood stasis, or it may generate accumulation of dampness or phlegm. Shen disturbance can be a result of either vacuity or repletion disease mechanisms that stem from dysfunction in other viscera and bowels; shen disturbance implies an imbalance in the heart’s function of housing the shen or spirit.

The most important viscera associated with the mechanism of depression are the liver, heart, and spleen; however, the kidney and lung also play important roles. The gall bladder and the stomach are the only two bowels that have special significance in depression. In brief, we will look at the role of each of these viscera and bowels in the precipitation of depressive episodes.

Acupuncture is said to adjust the density and flow of qi in the chan-nels and network vessels, which in turn affects the circulation of other vital substances (blood and body fluids) and the function of the viscera and bowels. Chinese medical theory, as it relates to acupuncture, encompasses five areas that provide the framework for assessment and treatment (Seem 1987). These areas are:

Eight guiding criteriaQi, blood, and body fluidsThe viscera and bowelsThe channels and network vesselsThe five phases.

Based on the training and style of the practitioner, one of these areas may be used primarily or several may be used in combination. We have explained in some detail some of the basic theoretical con-cepts that serve as the foundation for the aforementioned assessment areas. We now describe how the information gathered by examination is then organized using each one of these assessment areas as ‘filters’, through which we interpret the information.

The Eight Principles

The eight principles or eight guiding criteria are four sets of bipolar categories that help to differentiate and interpret the information gathered during examination (Beinfield & Korngold 1991). They serve as a conceptual matrix that enables the practitioner to organize the relationship between particular clinical signs and yin and yang (Kaptchuk 1983). Disease patterns can be identified by means of these eight fundamental principles: interior—exterior, cold—heat, vacuity—repletion and yin—yang. They determine the relative location, nature, and quality of the imbalance and constitute the basis of dif-ferential diagnosis from which the patterns of disharmony evolve. Interior and exterior describe depth of the disease; cold and heat describe the nature of the disease; vacuity and repletion describe the relative strength or weakness of one’s own right qi in relationship to pathogenic qi; yin and yang are the general categories that embrace the other six principles (Wiseman & Feng 1998). Interior, cold, and vacuity are yin features, whereas exterior, heat, and repletion are yang features. Each principle is associated with specific signs; by matching the patient’s signs the depth and nature of the diseases can be determined, as well as the relative strength of the.forces that resist the disease and those that cause it (Wiseman & Feng 1998).

Seem (1987) developed a phenomenological model that explains the mechanism for the development of vacuity and repletion patterns of either yin or yang, depending on one’s constitutional tendencies of `becoming hot’ (yang) or ‘becoming cold’ (yin). According to Seem’s model, we can interpret disease patterns as ‘somatic energetic reaction patterns’ that develop along one of two continua: yin deficiency—yang excess (hyperactivity and increased metabolic response) or yang deficiency—yin excess (hypoactivity, decreased metabolic response). In this view, when confronted with an emotional stressor or a perceived threat, the organism would tend to react in one of two ways: by activating sympathetic response in preparation for `fight or flight’ (yang) or by withdrawing from external activity and parasympathetically attending to internal demands and allowing the organism to ‘rest and digest’ (yin). If sympathetic activation is pro-longed, the organism exists in a chronic state of readiness, with the corresponding physiological reactions. Yang overtakes yin. If, on the other hand, the response is parasympathetic, the body will withdraw from action into a dependent stage, retreating from danger and looking for help. Yin overtakes yang (Seem 1987).6

We can use this interpretation of eight principles pattern differentiation to establish a parallel between these two reaction tendencies and the various symptoms of major depression. Each of the DSM-IV symptoms of major depression has corresponding symptoms of vacuity and repletion (deficiency/excess) of either yin or yang.

Qi, Blood, and Body Fluids

The mechanisms for the generation, transformation, and movement of qi, blood, and body fluids, which we explained above, are used as the conceptual matrix to understand the interactions and manifestations of yin and yang in the human body. Yin and yang are water and fire in the world, whereas qi and blood are fire and water in the body (Schnyer & Flaws 1998). As seen earlier, body fluids are also either yin or yang, depending on their function and nature. Essence and spirit also form a complementary yin and yang pair.

‘As we can see in Figure 3.1, if the yin of the kidney becomes situated on the left side of the five phases diagram, and the yang of the kidney on the right, when the yin of the kidney is vacuous or deficient ‘becoming hoe tendencies develop along the phases (and associated viscera) that are on the left; and ‘becoming cold’ tendencies due to yang vacuity develop along the phases (and viscera) on the right.

Clinically, when using qi, blood, and body fluids as a diagnostic filter, one determines the relative insufficiency or accumulation of qi and blood, the quality of generation, movement, and transformation of body fluids, and the condition and presence of the essence and spirit. In addition, the clinician evaluates the functional interactions between the viscera and bowels responsible with the production and movement of these ‘substances’. The use of qi, blood, and body fluids as a theoretical framework, in conjunction with the eight principles and the viscera and bowels, together constitute the foundation for TCM as a style of treatment.

Channels and Network Vessels

The network of channels in the human body is composed by four major systems: (1) the 12 regular channels, (2) the eight extraordinary vessels, (3) the secondary vessels, which include the tendinomuscular, connecting, and linking channels, and (4) the divergent channels. There are, in total, 71 channels (Seem 1990).

There are various approaches to using the channels and network vessels as a filter. For example, one may focus on knowing which level — defensive, nourishing, ancestral — is affected, in order to treat the corresponding network (Seem 1990). Alternatively, one may emphasize the treatment of the areas irrigated by the channels, as zones that are said to be structured and organized by the particular influence of each channel (Seem 1993). One may also use the concept of the six great units as constitutional diathesis (predisposition to disease) based on Yves Requena’s (1986) approach. The framework used throughout this manual incorporates these last two concepts: (1) the influence of the channels on different areas of the body when making our final point selection and (2) the six great units as consti-tutional diathesis, for understanding predisposition to the different pattern combinations.

The Channel System

The 12 Regular Channels

The 12 regular channels form the basic structure of the channel system and provide a network of qi and blood by which the whole body is nourished (Wiseman & Feng 1998). There are six yin and six yang channels, three of each on each hand and three of each on each foot. Each channel homes to viscera and bowels that stand in an interior—exterior (yin—yang) relationship. In addition to being paired by their internal—external relationship (yin—yang), the regular channels are also paired by the same polarity (yin or yang), with one arm channel and one leg channel to form the six great units; this results in a complex set of interactions that allow the acupuncturist to make subtle interventions to restore balance. Figure 3.2 lists the names of the 12 regular channels, their abbreviations, and their relationships.

The Eight Extraordinary Vessels

The eight extraordinary vessels are thought to develop prenatally before the development of the main channels; their function is to supplement insufficiencies of the other channels. The extraordinary channels do not home to any organs and do not have an interior—exterior relationship; they connect channels of the same polarity, whether yin or yang (Wiseman & Feng 1998). The extraordinary channels are du mai, ren mai, chong mai, dai mai, yang wei mai, yin wei mai, yang chao mai, and yin chao mai.

The Secondary Vessels

The secondary vessels include the tendinomuscular channels, the con-necting and the linking channels. The tendinomuscular channels run parallel to the regular channels on the surface of the body. The linking channels (luo) include 12 channels for each regular channel, plus one for du mai and one for ren mai. They extend the influence of the main channels to other parts of the body (Low 1983).

Two relationships between the channels are shown: in the right-hand column, the internal—external or yin—yang relationship is highlighted: one viscus and one bowel of the same phase are paired. On the left-hand side, the relationship that corresponds to the six units, between the upper and lower branches of each channel, is emphasized.This relationship underlines the correspondence between the viscus or bowel of one phase, with the viscus or bowel of a different phase.Adapted with kind permission from Seem ( 1987).

The Divergent Channels

The divergent channels leave the main channels at various points, but do not rejoin them; instead they join their coupled yang channel (Low 1983). They are considered of equal importance to the regular channels.

The channels are said to develop from conception through adult-hood; each channel level is said to carry a different kind of qi: defensive (wei), nourishing (ying), and ancestral (jing) (Seem 1990). The first to develop are three of the extraordinary vessels (du mai, ren mai, and chong mai; see below); then comes dai mai, followed by the remaining four extraordinary vessels. The second set of channels to develop are the tendinomuscular, followed by the regular, and finally the connecting, linking, and divergent pathways. For a summary of the different channel levels and their functions.

Channels and Network Vessels in the Treatment of Depression

In our protocol, we use primarily the regular channels because we are aiming at addressing dysfunction of the viscera and bowels. It is pos-sible, however, to develop a framework based on addressing the different channel levels mentioned above; it can be argued, for example, that depression is a stress response that should be treated initially at the level of the character armor (tendinomuscular level), or that one should aim at treating the core through the use of the extraordinary channels (Seem 1990). Clinically, it may be extremely useful to combine, in a progressive fashion, the use of the different levels. We hope to explore this possibility in the future. The present approach, however, involves solely outlining the rationale for the inclusion of some point combinations aimed at balancing two extraordinary channels, du mai and chong mai.

Du Mai

As summarized in this post, some studies conducted in China used points along du mai to treat symptoms associated with depression. Du mai, or the governing channel, plays a very important role in depres-sion. Du mai is one of the eight extraordinary channels and does not have a corresponding viscera or bowel. It emerges from the kidney; it is the storehouse of the yang, the sea of the yang channels, and has a regulating effect on the yang qi of the whole body. It begins its pathway at the perineum and ascends along the spine, up over the head and into the mouth. It is said in Chinese Medicine that the gov-erning vessel homes to the brain and nets the kidney. Since the kidney engenders the marrow and the brain is known as the ‘sea of marrow’, the governing vessel reflects the physiology and pathology of the brain and the spinal fluid, as well as their relationship to the reproductive organs (Wiseman & Feng 1998). The points along its pathway have been used traditionally, among other things, to affect mental func-tions. An excess of qi along the channel would mean an exuberance of yang: too much energy traveling ‘upward’ towards the head or stuck in the upper part of the body creating irritability, restlessness, and insomnia. An insufficiency in the flow of qi along its pathway will result in the inability of total yang of the organism to circulate, raise, and nourish the brain and spinal cord, manifesting as apathy, flat affect, and inability to express enthusiasm or emotion. The section on point indications provides greater detail on how we have used du mai in our protocol.

Chong Mai

Chong mai is where all the qi and blood of the 12 regular channels converge and it is considered to have a regulating effect on all of them (Wiseman & Feng 1998). The transportation and movement of the qi and blood of the whole body is focused on the chong, and therefore it is called the ‘sea of blood’ (Flaws 1997). The chong mai arises from the kidney and connects the liver with the pericardium (jueyin), bringing together the functions of menstruation (liver) and reproduction (kidney) with the heart’s function of housing the spirit. Chong mai is traditionally indicated in the treatment of menstrual and gynecological disorders, and it is broadly used to treat morning sickness during pregnancy.

In its pathway, the chong mai raises up through the regions irrigated by the liver and kidney (yin), connecting the peritoneum, the pleura, and the pericardium, and serving as the foundation upon which all the functions of the viscera and bowels develop (Seem 1990). The chong mai comprises the entire visceral cavity, and integrates the areas primarily affected by stagnation of liver qi.

The liver rules the area of the diaphragm and the region of the ribs. When confronted with a stressor, one commonly tightens up the diaphragm as well as the musculature of the chest and the upper back, the throat, the jaw, and the head. If this constriction of the diaphragm develops into a chronic stress response, the upper and lower regions of the body become ‘split’, as if one was cut off, so to speak, at the diaphragm, leaving the lower parts of the body vacuous and weak (kidney yang vacuity) and creating hyperactivity and agitation in the upper parts of the body (shen disturbance). In people experiencing depression, it is very common to find a constriction in the diaphragm, and neck and shoulder tension (liver qi stagnation), in combination with symptoms of decreased metabolic response on the one hand (kidney yang vacuity) and anxiety and agitation (yin vacuity—hyper-activity of yang) on the other. Chong mai allows us to integrate the complex relationship of patterns found in depression that involve the liver, the heart, the spleen, and the kidney simultaneously.

The Five Phases

The relationship between yin and yang is further differentiated into identifiable stages that describe the process of change between situations and across time. These stages — wood, fire, earth, metal, and water — are known as the five phases and reflect the transformation of yin into yang, and vice versa. Like yin and yang, the five phases are categories of quality and relationship (Wiseman & Feng 1998). Change is a process that takes place gradually as qi moves around the cycle represented by the five phases. According to the five phases theory, phenomena in the universe are the result of the movement and mutation of these five entities. Wood, fire, earth, metal, and water rep-resent certain qualities and relate to one another in specific ways; any other group of five phenomena that have qualities and relate to each other in similar ways are said to correspond to the five phases (Wiseman & Feng 1998;).

Yin, which expresses the potential of the bodymind (i.e. totality of soma and psyche), is characterized by water, and corresponds to the apparent quiescent stasis of the winter — a time when, beneath the surface, germination is preparing to bring forth the renewal of spring. It represents the capacity to store, generate, charge, and restore after release (Beinfield & Korngold 1991). Water is the moistening and descending to low places’ (p. 206); it corresponds to the blackness of the night, and with saltiness, the taste of sea water (Wiseman & Feng 1998).

Fire characterizes yang, the dynamic principle, the sense of splendor and fulfillment experienced when light, warmth, and interaction are at their peak. Fire symbolizes the end point of expansion and con-summation, of completion and fulfillment (Beinfield & Korngold 1991). ‘Fire is the flaming upward, and has the quality and upward movement’ (p. 205); it is associated with summer, with the color red, and the bitter taste (Wiseman & Feng 1998).

The transition of yin (the seed and the root) into yang (the flower and fruit) is represented by wood, an ascending movement of sudden growth and rapid expansion, of unexpected but unpredictable change (Beinfield & Korngold 1991). Wood is the bending and the straightening’ (p. 205), it grows upward and stretches outward; it corresponds to the spring, the time of growth and the beginning of the cycle of the seasons, it is associated with the green of new leaves in the sour taste of unripe fruit (Wiseman & Feng 1998). When the life force reaches its greatest expression, it begins to slow down, collapsing inward.

Metal represents the capacity for separation and refinement that is expressed in the autumn, when the energy contracts in order to consolidate, when the leaves fall and fertilize the soil for the next spring (Beinfield & Korngold 1991). ‘Metal is the working of change’ (p. 206), having the qualities of purification, elimination, and reform; it is associated with the white color of frost, and with the purifying action of acrid smelling things (Wiseman & Feng 1998).

These processes happen as we find ourselves on the earth, the point of reference that locates us in time and space. Earth represents our capacity for changing direction without losing balance, and is the axis around which other aspects orient themselves (Beinfield & Korngold 1991). ‘Earth is the sowing and reaping’ (p. 206), representing the planting and harvesting of crops and the bringing forth of phenomena. Earth is associated with yellow (the Chinese word includes brown), and with the sweetness of ripened fruit (Wiseman & Feng 1998).

Clinically, the five phases constitute a system for understanding the movement of qi through the five viscera; each of the five viscera corresponds to each of the five phases. Wiseman & Feng (1998) illustrate the relationship between the functions of the five viscera and the qualities of the five phases as follows:

`The liver controls the movement of qi around the body; it spreads qi just as the trees spread their branches; and as trees and other plants sprout upwards in the spring, so the liver yang tends to stir upwards. The heart has the function of propelling qi and blood to warm and nourish the whole body; it is like a fire that drives the body, just like the heat of summer makes nature flourish. The spleen is the source of qi and blood, that nourish and drive the body, just like the earth brings forth the crops at the end of the summer. The lung helps transform the fluids into blood, it controls the downward movement of the fluids to the kidney and bladder, and in this way is responsible for the purifying removal of waste fluids; it has the purifying qualities of the autumn frost. The kidney stores essence, just as nature preserves itself in winter dormancy.’ (Wiseman & Feng 1998, p. 206)

The five phases explain the etiology and nature of qi imbalances, providing in this way the framework for an energetic physiology to further comprehend the disturbances of the bodymind (Seem 1987). In addition to having similar qualities to one another, the phenomena associated with the five phases relate to other phenomena associated with the same phase in a similar fashion; for example, water engenders wood, and winter gives way to spring, and so the kidney (water) nourishes the liver (wood). Each phase corresponds to a set of channels and to a viscus and a bowel paired by their yin—yang relationship. (Each paired system is commonly identified by the name of the yin function: liver—wood, heart—fire, spleen—earth, metal—lung, water—kidney.)

According to Beinfield & Korngold (1991), every viscus and bowel has a responsibility or job to do, a strategy on how to do the job, and a character or way to do it, which reflects the nature of the energy represented by its pertaining phase. Every phase characteristically influences physiological and psychological functions that in turn correspond to the particular viscus (and bowel) associated with it. There is a corresponding tissue, sense, body fluid, sound, and smell associated with each phase. In addition there is an emotion and a mental aspect associated with each of the five phases. A more comprehensive description of the correspondence between the five phases, the five viscera, the emotions, and the mental aspects associated with each one of them is given in ‘The seven affects and the five emotions’ and ‘The five spirits’ sections below.

Correspondences of the five phases

In the context of the five phases, depression can be considered an imbalance in the movement of qi along the cycle of transformation of the energy. The five phases interact with one another according to pat-terns of generation and restraint which explain their capacity and provide the motivating impulse for their potential (Beinfield Korngold 1991). Illness is considered a process, not a static entity. When using the five phases as the basis for diagnosis and treatment, the system of correspondences is used to identify constitutional tendencies and to determine the configuration presented by the interaction of signs and symptoms, in order to attend to the root of the patient’s imbalance. Emotional disturbances are well explained using the theory of the five phases as a framework, which makes it an especially useful tool to understand distinct constitutional predispositions to depres-sion, to reframe the symptoms experienced by the person, and to develop a model for patient education.

As seen above, each of the five phases and its corresponding viscus has an associated emotion. These five emotions — anger, joy, worry, sadness, and fear — are considered to be manifestations of qi, basic forms of emotional activity; they become a cause of disease only when experienced excessively, for a prolonged period of time, or both (Maciocia 1994). Two emotions, anxiety or oppression, and fright, are added to these five to complement the gamete of human emotions; together they constitute the seven affects. Oppression reinforces other emotions such as sadness, obsessive thinking, or fear; it represents contraction, lack of circulation, immobilization (Larre & Rochat de la Vallée 1996); sometimes translated as anxiety (Wiseman & Feng 1998), this emotion is attributed to the lung or spleen, depending on the context (Larre & Rochat de la Vallee 1996). Commonly, fright refers to being startled with fright, and can mean any movement of the body, such as shaking or convulsions; it corresponds to the liver.

When disease originates from emotional causes it is known in Chinese Medicine as internal damage, affect damage, or damage by the emotions. (In Chinese Medicine, disease is said to originate from one of three causes: internal, external, or neutral (neither internal nor external). The emotions are said to be the internal causes of disease and are not to be confused with evils that arise internally such as internal fire or internal wind, which may develop from affect damage, but which can also be the result of insufficiency or transformation of external evils (Wiseman & Feng 1998).)

When the emotions are experienced persistently or intensely, they can alter the balance between yin and yang, blood and qi, and adversely affect the functions of the viscera and bowels. For example, whereas the liver, heart, and spleen seem to be involved most directly with the core symptoms of major depression, the interactions of these with other viscera and bowels can play a role in the appearance of other physical and psychological symptoms that may be seen during depression. These are symptoms for which depressed individuals may visit a physician, only to find no medical basis for their complaints. Because all symptoms, both physiological and psychological, are rele-vant in Chinese Medicine, these additional symptoms are equally important in determining the pattern of disharmony underlying depression. These symptoms help to establish the diagnosis and selec-tion of treatment principles and points.

For example, anger causes the qi to rise and can create distension and fullness in the rib cage and breasts, headaches, dizziness, and red, sore eyes; because the liver stores the blood, ascendant liver qi may carry the blood with it and cause nose bleeding. Because the liver and the spleen are closely related through the control cycle of the five phases, excessive liver qi moves across, ‘attacks’ and affects the spleen, making it incapable of performing its functions of transportation and transformation. A very common scenario encountered in depressive episodes is liver qi stagnation (frustration, irritability) in conjunction with a weak spleen, or spleen vacuity (weight changes, worry, abdominal distension); this weakness of spleen may, in turn, generate dampness or phlegm accumulation (yin repletion). Anger can also affect the stomach (nausea/vomiting), large intestine (irritable bowel), lungs (coughing and wheezing), and heart (agitation, insomnia).

Joy causes the qi to slacken; excessive joy leads to a dissipation of shen, or spirit, and a weakening of the heart qi, manifesting as heart palpitations, insomnia, and some mental diseases (Wiseman & Feng 1998) such as mania. Worry and overthinking cause the qi to bind, affecting movement and transportation and causing shallow breathing, fullness in the chest (lungs) and stomach, poor appetite, abdominal distension, and loose stools. They can also cause neck and shoulder stiffness (gall bladder, liver) (Maciocia 1994).

Sadness (grief) corresponds to the lungs. It causes the qi to disperse and can deplete lung qi, which manifests with a weak voice, breath-lessness, and weeping, or a feeling of constriction in the chest. According to Maciocia (1994), sadness may also affect the liver and create mental confusion, a lack of sense of direction, and an inability to plan; when held in for many years, it can affect the kidney and its regulation of fluid metabolism.

Incontinence or diarrhea may be caused by fear, which makes the qi descend and corresponds to the kidney. Fright, which in the summary above is associated with the heart, causes chaos and derangement of the qi, manifesting as disquietude of the spirit, and possibly more severe mental illness (Wiseman & Feng 1998).

Affect damage or damage by the emotions can originate from and/or give rise to vacuity or repletion patterns. Shen disturbance vacuity patterns manifest primarily as heart blood or heart yin vacuity, and to a lesser extent as heart qi vacuity; they generally stem from constitutional or circumstantial predisposition to qi and blood vacuity. Shen disturbance repletion patterns stem from either liver depression or spleen and kidney vacuity. -When originating from liver depression, they manifest as qi stagnation affecting the heart, depres-sive heart agitating the spirit, or blood stasis blocking the heart’s orifices; when stemming from spleen and kidney vacuity, they manifest as variety of patterns that derive from phlegm obstructing the orifices of the heart.

The Five Spirits: Five Mental Aspects of the Bodymind

In addition to the spirit (shen), which is stored by the heart, each yin viscus houses a specific mental aspect of the human mind. The shen itself indicates consciousness and memory; it maintains our awareness and expresses the integration of our being. The liver stores the hun, usually translated as the ethereal soul. The hun is said to complement the functions of the shen, and it is related to intuition and inspiration, insight and courage. The hun gives us a sense of direction and the capacity for planning; it influences sleep and dreaming. In the spleen is stored the yi or reflection, which represents our verbally expressed thoughts, our capacity for applied thinking, studying, memorizing, focusing, concentrating, and generating ideas. The kidney stores the zhi, which corresponds to will, drive, and determination; it also pro-vides us with the capacity to store information and is related to long-term memory. The po or corporeal soul is stored in the lung and is what gives the body its capacity for movement, physical sensation, and coordination. It can be linked to the physical expression of the hun or to the organizational principle of the body, and it is considered to be closely related to the essence, considered the foundation of human life.

Depending on the specific manifestations, severity, and precipitating factors in a depressive episode, one or more of these mental aspects will be affected.

The Five Virtues and other Correspondences of the Five Phases

Any human quality, mental attribution, or emotional experience can be attributed to the five phases. For example, each of the five spirits has a primary responsibility for a particular virtue (Kaptchuk 2000). Shen, which resides in the heart and corresponds to fire, is responsible for ceremony and propriety (li). ‘Propriety ensures that correct behavior fosters timely interactions and relationships’ (Kaptchuk 2000, p. 64). Hun, which resides in the liver and corresponds to wood, is responsi-ble for human kindness and benevolence (ren): ‘it has an intimate rela-tionship to a person’s capacity to feel and endure pain’ (Kaptchuk 2000, p. 61). In the spleen resides the yi, which corresponds to earth and is responsible for ‘faithfulness, loyalty or sincerity (xin) and has the task of enabling and supporting new manifestations to come into being’ (Kaptchuk 2000, p. 60). Zhi, which resides in the kidneys and corresponds to water, is responsible for the virtue of wisdom (zhi): ‘a knowing that has to do with learning to have a relationship to what is unknown and what is unknowable … a deep trust that the unknown eventually reveals an inevitable destiny’ (Kaptchuk 2000, p. 62-63). In the lungs, which correspond to metal, resides the po. The po is respon-sible for the virtue of preciousness (bao). ‘The Po is said to capture the perfection and completeness of a single moment or a short time span’ (Kaptchuk 2000, p. 65).

In Chinese Medicine, virtue refers to impulse from which all things manifest through the movement of qi (Larre & Rochat de la Vallée 1995). In the Ling Shu, it is said: ‘Heaven in me is Virtue. Earth in me is Breaths. Virtue flows, Breaths spread out, and there is Life’ (Larre & Rochat de la Vallée 1991a, p. 87). In the human being, `virtue is the authenticity of the heart as it moves along’, ‘through virtue one both finds and possesses oneself, and ‘virtue gives authen-ticity to the one that possesses virtue’ (Larre & Rochat de la Vallee 1995). For a more complete interpretation of the five phases, their correspondences, and their clinical application, refer to the numerous books of Claude Larre & Elisabeth Rochat de la Vallée, such as The Seven Emotions and Rooted in Spirit, and to Harriette Beinfield & Efrem Korngold’s Between Heaven and Earth and to Lonny S. Jarrett’s Nourishing Destiny.

Application of Traditional Chinese Medicine in the Diagnosis and Treatment of Depression

The absence of understanding of the disease mechanisms that precipitate the patterns and of the rationale for point selection will provide, at best, a mechanical cook-book approach to treatment that will fail to address the complexity of depression as experienced by most people.

Based on the proposed framework, depressive episodes are generally characterized by the combination of various patterns. To deter-mine the disease mechanisms relevant to the different pattern combinations, one needs to evaluate to what extent the following four features are present in each person:

Qi stagnation, stemming from the liver’s inability to perform its function of coursing and dischargeShen disturbance, arising from the heart’s inability to perform its function of housing the spirit (shen) due to either vacuity or repletionYin features including (a) qi and yang vacuity (yang) and/or (b) repletion of dampness and phlegm (yin)Yang features including (a) yin and blood vacuity (yin) and/or (b) repletion of heat or fire (yang).

In addition, one needs to identify which specific viscera and bowels are involved. Generally, a person experiencing depression does not fit only one pattern, and similarly does not present with an imbalance in only one viscus or bowel. It is common clinically to encounter a complex combination of patterns which includes elements of these four features. The particular complex pattern combination will determine the treatment principles and the individually tailored treatment plan. For example, a person might present with: (1) stagnant liver qi, trans-forming into heat (depressive heat), and (2) heart blood vacuity, and (3) spleen qi vacuity. The pattern then will be: liver depression transforms heat, heart—spleen dual vacuity. The treatment principles will be: course the liver and rectify the qi, clear heat and resolve depression, fortify the spleen and nourish the heart, boost the qi and supplement the blood.

Traditionally, the disease mechanisms are evaluated first, then the patterns and combination of patterns are determined, then the treat-ment principles are outlined, and finally a treatment plan is designed. Some of the patterns emerging from the four features mentioned above, and some pattern combinations, are particularly relevant in depression, while others are not. To facilitate pattern differentiation and to clarify the disease mechanisms underlying depression, the pat-terns that become the building blocks for more complex patterns will first be reviewed. Within the description of each pattern, the natural progression of depression patterns will be described, and then common pattern combinations may be listed under ‘special consider-ations’ for that pattern. Then the 12 most commonly encountered basic and combined patterns that precipitate depression will be listed.

At the end of this post there is a summary that presents this information in condensed form for easy reference.

The main basic patterns involved in major depression are:

1. Qi stagnation

Liver depression qi stagnationLiver depression transforms heatQi stagnation affecting the heart and lungBlood stasis and stagnation

2. Shen disturbance: vacuity

Heart blood vacuityHeart qi vacuityHeart yin vacuityHeart fire flaming upward (heart yin vacuity with vacuity heat)

Qi stagnation

Liver depression qi stagnation

Disease causes, disease mechanisms: Emotional stress, anger, and frus-tration cause the liver to lose its ability to regulate coursing and discharge; there is emotional depression and lack of smooth flow of the qi mecha-nism.The qi becomes stagnant along the pathway of the liver channel, which traverses the lower abdomen and stomach, and spreads across the chest and sides of the ribs. One may see abdominal and chest oppression, pain along the ribs; if the liver attacks the stomach, the stomach loses its harmony and downbearing; there may be epigastric oppression, belching and burping, possibly nausea and vomiting; if it affects the spleen, there is loss of appetite, abdominal distension, and diarrhea.

Main symptoms: Chest, lateral, costal, breast and abdominal distension and oppression, sighing, dysmenorrhea, irregular menstruation, premenstrual tension, a feeling of a lump in the throat; nausea, vomiting, hiccups, burping, belching, if the liver is invading the stomach.

Symptoms associated with depression: Irritability, mental depression, moodiness, feeling wound-up, alternation of moods, snapping easily, and an intense feeling of frustration.

Pulse: Wiry.

Tongue: Normal or slightly dark, thin coating.

Treatment principles: Course the liver, rectify the qi, and resolve depression. Main acupuncture points: Lv 3, L I 4.

Additional points: Lv 14, UB 18.

Adjacent points:

n  For chest and breast distension and pain: Ren 17 or Sp 21

n  For lower abdominal distension or pain: Ren 6, Ren 4, St 28, St 29

n  For hypochondriac distension and pain: Lv 14

n  For epigastric fullness and distension: Ren 12.

Special considerations: Only in very acute and uncomplicated depressive episodes may liver depression qi stagnation cause depression all by itself. Liver depression qi stagnation usually combines with, and aggravates, pre-existing tendencies towards imbalances in other viscera and bowels. The specific mechanisms triggered by a failure in the functions of coursing and discharge determine the individual’s symptoms of depression, the nature and duration of the depressive episode, and the prognosis and outcome of the treatment. However, most major depressive episodes seem to involve liver depression qi stagnation as a significant component. In dysthymia as well as recurrent, chronic, and recalcitrant depression, liver depression qi stagnation seems to precipitate phlegm obstruction and blood stasis, and/or occurs on a background of long-standing constitutional insufficiency.

Qi stagnation

Liver depression transforms heat

Disease causes, disease mechanisms: Extreme or long-term stagnation of liver qi will eventually transform into heat. Because heat is yang in nature, it tends to counterflow or move upwards, negatively affecting the function of organs (stomach, heart, and lungs) and tissues (head, mouth, nose, ears, and eyes) located above the liver. In addition to symptoms of qi stagnation, there will be symptoms of heat. This heat can force the blood to move recklessly, outside its pathways. Because the spirit resides in the heart, upwardly counterflowing depressive heat may disturb the heart spirit, causing it to become restless. (See below under Depressive heat affecting the heart or lung.)

Main symptoms: Insomnia, excessive dreams, chest oppression, agitation, red eyes, red facial complexion, acne, heart palpitations; breast distension but more prominent pain, hypersensitive nipples; bitter taste in the mouth, thirst; early or excessive menstruation, dysfunctional uterine bleeding.

Symptoms associated with depression: Irascibility, easy anger, impetu-osity, mental restlessness, aggression, violent outbursts of anger.

Pulse: Wiry and rapid.

Tongue: Darl< and red and/or swollen edges, with a thin yellow coat. Treatment principles: Course the liver and rectify the qi, clear heat, and resolve depression.

Main acupuncture points: UB 18, UB 15, Lv 2 and Lv 3, LI 4, LI I 1, P 7, Ht 5. Additional acupuncture points: Add points to settle the heart and calm the spirit, and/or points to open the chest and stimulate the descending of lung qi.

Special considerations: When enduring or severe liver depression trans-forms into heat or fire, this heat is known as depressive heat. In addition to anger and frustration, any of the seven emotions may transform into fire, if extreme. Depressive heat may be aggravated by heat accumulating in the stomach due to eating hot, spicy, and greasy fatty foods or drinking alcohol. lf, in addition to liver depression qi stagnation, there is dampness and phlegm due to spleen vacuity, the stomach may further lose its ability to digest the food, and food may accumulate. It is not uncommon to find symptoms of food stagnation such as bad breath, nausea, indigestion, thick, slimy tongue fur, and a slippery pulse complicating other patterns. As we age, depression transforms into heat more readily; heat and fire tend to evaporate and consume blood and yin, and aggravate the natural predisposition to yin vacuity that is part of the process of aging.

Qi stagnation

Qi stagnation affecting the heart and lung

Disease causes, disease mechanisms: When sadness and grief remain for a long time they deplete the qi and lead to qi stagnation in the chest, which is ruled by both the heart and the lungs.Worry knots the qi and can also give rise to this pattern.

Main symptoms: A feeling of oppression and tightness in the chest, palpi-tations, sighing, slight breathlessness, a feeling of a lump in the throat with difficulty swallowing, pale complexion.

Symptoms associated with depression: Sadness, a tendency to weep, accompanied by anxiety, easily affected negatively by the problems of other people.

Pulse: Weak, with no wave, specially in the cun position both sides. It may also be slightly wiry, although at the same time it is vacuous and weak. Tongue: It can be slightly red in the chest area (sides of its central section). Treatment principles: Rectify and move the qi, stimulate the descending of heart and lung qi, and calm the spirit.

Main acupuncture points: Lu 7, Ht 7, P 6, Ren 17, Ren I 5.

Additional points: St 40, LI 4, SI 5, GB I 8.

Special considerations: This pattern is characterized by underlying lung qi vacuity, and possibly by heart blood vacuity in combination with liver depression.The qi stagnates primarily in the chest area, affecting the lung’s function of governing qi (breathing and production of true qi) and to some extent the heart’s function of governing blood (movement of blood), which are complementary to each other.There may be slight dampness or phlegm accumulation due to both lung and spleen qi vacuity. The difference between this pattern and depressive heat affecting the heart and/or lungs is that, in this case, the vacuity is more prominent and there is very slight or no depressive heat.

Qi stagnation

Blood stasis and stagnation

Disease causes, disease mechanisms: Enduring or severe liver depres-sion may lead to an inability of the qi to move the blood; the blood becomes static because the qi is stagnant, so there is a combination of signs and symp-toms of liver depression qi stagnation and symptoms of blood stasis.

Main symptoms: Abdominal distension, stabbing, fixed pain, formation of masses or swellings, dark purple, clotted bleeding (specially vaginal); dark complexion, rough, dry, and lusterless skin, with red speckles or purple macules, spider veins, prominent green-blue veins in the abdomen; in addi-tion to signs and symptoms of qi stagnation.

Symptoms associated with depression: Vexation, agitation, thoughts of suicide, severe insomnia; chronic, recalcitrant, or severe depression. Pulse: Fine, choppy.

Tongue: Dark, purple, with stasis speckles. Purple, distended veins under the tongue.

Treatment principles: Quicken the blood and transform stasis.

Main acupuncture points: UB 17, SP 10, SP 6, SP 8, Per 3.

Additional acupuncture points: Points used to course the liver and rectify the qi.

Special considerations: Blood stasis may result from long-standing liver depression not moving the blood, but it can also result from traumatic injury, from blood vacuity not able to nourish the vessels and keep them open, from qi vacuity not able to push the blood, or from cold congealing the blood. Because static blood hinders the creation of new or fresh blood, blood stasis may precipitate blood vacuity, and blood vacuity may precipitate blood stasis. If blood stasis is referred to the liver specifically, this means that the stasis is particularly manifest along the path traversed by the liver channel: the pelvic region, abdomen, chest, throat, and head. In depression, blood stasis either results from enduring liver depression qi stagnation or is a further complication of an underlying pattern. Blood stasis may complicate many cases of depression, especially in women who may often experience blood stasis as a factor in either the uterus, the breasts, or both.

Shen disturbance: vacuity

Heart blood and heart qi vacuity share several features in common. Before listing the features unique to each, the common features will be discussed. General symptoms for shen disturbance caused by either heart blood or heart qi vacuity: Insomnia, heart palpitations, mild anxiety, poor memory, mild dizziness, easily startled.

General treatment principle for heart blood or heart qi vacuity patterns: Nourish the heart and calm the spirit (boost the qi and sup-plement the blood).

Main acupuncture points for heart blood and heart qi vacuity patterns: UB 15, UB 44, Ren 14, Ren 15, Ht 7, P 6.

Heart blood vacuity

Disease causes, disease mechanisms: As a result of constitutional insufficiency, enduring disease, aging, blood loss, or prolonged sadness and grief, there may be insufficient blood to nourish the heart.

Main symptoms: Fright palpitations, restlessness, suspiciousness, insomnia with an inability to fall asleep, excessive dreams, mild anxiety, mild dizziness, propensity to be startled, dull pale complexion, poor memory, lassitude of the spirit.

Symptoms associated with depression: Depression with fatigue, confu-sion, lack of concentration.

Pulse: Fine, possibly choppy.

Tongue: Pale and thin, with a thin white coat.

Treatment principles: Nourish the heart and calm the spirit, supplement the blood.

Main acupuncture points: In addition to general points above, Ren 4, St 36, Sp 6, Sp 4.

Additional acupuncture points: UB I 7, Sp 10, P 7.

Special considerations: Because the spleen is the source of engender-ment and transformation of both qi and blood, heart blood vacuity is com-monly encountered in clinical practice in conjunction with spleen qi vacuity. This pattern is known as heart—spleen dual vacuity (refer to the section below on Spleen qi vacuity).

Shen disturbance: vacuity

Heart qi vacuity

Disease causes, disease mechanisms: Constitutional insufficiency, over taxation, too much thinking and worrying, sadness, grief and regret, endur-ing diseases, aging, blood loss.

Main symptoms: Shortness of breath and heart palpitations aggravated by exertion, insomnia, mild anxiety, poor memory, mild dizziness.

Symptoms associated with depression: Lack of motivation, fatigue and exhaustion, poor sleep.

Pulse: Fine, weak, regularly interrupted pulse.

Tongue: Pale with a thin white coating.

Treatment principles: Supplement the heart, nourish the blood, and calm the spirit.

Main acupuncture points: In addition to the main points above, Ren 4, St 36, Sp 6, Sp 4.

Additional acupuncture points: UB 20, UB 21, Du 20.

Special considerations: Heart qi vacuity is rarely seen by itself in actual clinical practice. Two subpatterns of heart qi vacuity in the Chinese Medicine literature are heart qi not securing (the spirit), characterized by confusion, impaired memory, easy fright, spontaneous perspiration on movement. The second subpattern is heart qi inability to lie down, when the heart qi is insufficient, the spirit will not be quiet, and it is difficult to lie down at night to sleep; the person is easily aroused from sleep, there are heart palpitations, a lack of strength, lassitude of spirit, aversion to cold, and a slow, forceless pulse.

Heart yin vacuity

Disease causes, disease mechanisms: Fear and worry combined with overwork for many years, aging, and congenital insufficiency may all lead to yin vacuity. In addition, enduring depressive heat may consume and evapor-ate blood and yin.

Main symptoms: Heart palpitations, insomnia (inability to stay asleep or wal

Symptoms associated with depression: Dispirited, depressed, and tired, yet anxious and restless at the same time; lack of willpower and drive. Pulse: Rapid and thin, or floating and vacuous.

Tongue: Red tongue, redder tip, without coating.

Treatment principles: Enrich yin, settle the heart, and calm the spirit. Main acupuncture points: UB 15, UB 44, Ren 14, Ren 15, Ht 7, P 6. Additional acupuncture points: P 7, Kd 6, Kd 3, Kd I 0, Sp 6.

Shen disturbance: vacuity

Heart fire flaming upward (heart yin vacuity with vacuity heat)

Disease causes, disease mechanisms: If depressive heat counterflows and accumulates in the heart, it may eventually consume and damage yin and blood, in which case yin will be unable to control heart yang which then becomes effulgent and hyperactive.

Main symptoms: Heart vexation, chaotic spirit, insomnia, excessive dreams, fright palpitations, racing heart, dryness of the mouth and throat, and flushing. In general, heart yin vacuity symptoms are more pronounced, anxiety and restlessness will be extreme, and the sleep will be more severely disturbed.

Symptoms associated with depression: Mentally, the person may become aggressive and very impatient.

Pulse: Floating or surging, in addition to being rapid and thready.

Tongue: Red, mirror with more pronounced redness of the tip.

Treatrnent principles: Enrich yin, clear heat, and drain fire; settle the heart and calm the spirit.

Main acupuncture points: Same as for yin vacuity above; in addition use Ht 6.

Special considerations: Heart fire flaming upward can be either a vacuity or repletion pattern, characterized by upper body signs (reddening of the tip of the tongue, vexation, cracking of the tongue, and erosion of the oral and glossal mucosa, rapid pulse). Here we are referring to heart fire due to heart yin vacuity, which is in turn due to kidney yin vacuity (heart—kidney not com-municating); it is therefore necessary to supplement the kidney in order to enrich yin.As a repletion pattern, heart fire flaming upward is due to hyper-active heart fire, which in turn is due to liver fire (see below underYang reple-tion patterns); in that case there is headache, red eyes, agitation, and irascibility in addition to the symptoms above. Heart fire may also spread to the small intestine, where it manifests as painful, dribbling, reddish urination.

Shen disturbance: repletion

Qi stagnation affecting the heart and lung

This is a repletion pattern that stems from a progression of liver qi stagna-tion, and is therefore discussed under Qi stagnation above.

Depressive heat affecting the heart or lung

This is also a repletion pattern that develops from qi stagnation transforming into heat; the disease causes, disease mechanisms, treatment principles, and points are discussed above under Liver depression transforms heat. Depressive liver heat due to emotional stress and frustration may travel upwards and accumulate in the heart and lungs. If it accumulates in the heart, it causes vex-ation, agitation, anxiety, insomnia, and restlessness. If it accumulates in the lungs, it causes weepiness and sadness.

Exuberant heart fire

Disease causes, disease mechanisms: Fire in the heart develops from below. It is either due to enduring emotional stress and frustration, which cause the ministerial fire to stir up and counterflow, or it is due to overeating sweet, greasy, spicy food and drinking alcohol, which cause spleen damage that leads to yin fire counterflow.

Main symptoms: Heart vexation, agitation, insomnia with excessive and disturbing dreams, racing heart, restlessness that is projected outward or is accompanied by compulsive behavior; ulcers in the mouth and on the tongue; frequent, urgent, yellow urination, dry stools, red face, red, painful, swollen, skin sores.

Symptoms associated with depression: Recurrent suicidal ideation, possibly with suicidal attempts; aggression, violent outbursts; if severe, manic agitation and delirious speech.

Pulse: Rapid, wiry, and possibly slippery or surging pulse.

Tongue: Red with a yellow coat.

Treatment principles: Clear the heart, drain fire and lead it downward, and settle the spirit.

Main acupuncture points: Ht 8, Ht 5, P 7, Ren I 5, GB I 5, Sp 6.

Additional acupuncture points: Du 14, LI 4, LI I I, P 8, Ht 3.

Phlegm confounding the heart (orifices)

Phlegm (heat) fire harassing the heart.

Qi/yang vacuity

Qi and yang vacuity tends to occur as a continuum, because yang is generated by the movement of qi.Yang vacuity usually implies that, in addition to signs and symptoms of qi vacuity, there is also the presence of cold.

Spleen qi (and lung qi) vacuity

Disease causes, disease mechanisms: Overwork and prolonged stress; poor diet, overeating raw and chilled foods, or undereating; overthinking and too much worry over a long period of time; chronic illness, lack of exercise.

Main symptoms: Fatigue, weakness, lethargy, loose stools, poor appetite, pale face, faint voice.

If lung qi vacuity is also present: Shortness of breath, spontaneous sweating, cough, all aggravated upon exertion.

Symptoms associated with depression: Depression with fatigue, slow thinking and speaking, slow movements, poor memory and concentration, decreased motivation, diminished interest or pleasure, excessive desire to sleep, apathy, excessive guilt, obsessive thinking or phobias, lassitude of spirit.

Pulse: Relaxed, or soggy annd weak.

Tongue: Pale, swollen, with thin white coating.

Treatment principles: Boost the qi, fortify the spleen (and the lungs). Main acupuncture points: UB 20, UB 21, UB 49, Ren 4, Ren 6, Ren 12, St 36, Sp 3.

For lung qi vacuity: Add Lu I , Lu 9, Lu 7, UB 13, UB 42.

Special considerations: Too much work, or even too much exercise, may consume the qi and blood, whereas too little exercise causes the qi to become stagnant. A diet of too many raw, cold, chilled foods may exhaust the digestive fire of the spleen; too many sweets, dairy products, and fried foods may also damage the spleen.As explained above, liver depression may also give rise to or exacerbate spleen vacuity.The spleen is usually the first viscus to become diseased after the liver has become depressed. If the spleen becomes vacuous and weak, it will not engender and transform the qi and blood properly, leading to vacuity of both heart blood and spleen qi (heart—spleen dual vacuity). If heart blood is too vacuous to nourish and quiet the spirit, the spirit may become hyperactive and restless, or it may be unable to engage the world and respond to the environment.

Qilyang vacuity

Spleen yang vacuity

Disease causes, disease mechanisms: Enduring spleen qi vacuity or severe damage due to enduring disease; aging, or overeating raw, chilled foods.

Main symptoms: In addition to spleen qi vacuity symptoms above; edema, cold body with chilled extremities, abdominal distension and fatigue after eating, dull abdominal pain that likes warmth and pressure.

Symptoms associated with depression: More pronounced symptoms than in spleen qi vacuity.

Pulse: Sunken, forceless, or even slow.

Tongue: Swollen and pale, with teeth marks on the borders; a thin, white, slightly slimy coat.

Treatment principles: Supplement the qi and warm the spleen.

Main acupuncture points: Same as for spleen qi vacuity above. Moxa is applicable.

Kidney qi vacuity

Disease causes, disease mechanisms: Constitutional insufficiency, aging, or chronic disease; enduring spleen qi vacuity.

Main symptoms: Low back and knee soreness and weakness, premature graying or loss of hair, impotence or frigidity, uterine prolapse with weak-ness in the low back, frequent urination, night urination, tinnitus, dizziness, diminished auditory acuity.

Symptoms associated with depression: Mental and physical exhaustion, no willpower or initiative; hopelessness about getting better or starting or changing anything. Everything is too much effort.

Treatment principles: Nourish the kidney and supplement the qi. Pulse: Deep and weak.

Tongue: Pale red tongue.

Main acupuncture points: UB 23, UB 52, Du 4, Ren 6, Kd 3, Kd 7.

Qi/yang vacuity Kidney yang vacuity

Disease causes, disease mechanisms: Constitutional insufficiency. aging, or chronic disease; overwork, excessive sexual activity, or drug use.

Main symptoms: In addition to the symptoms for kidney qi vacuity above: a cold feeling in the lower part of the body, lower abdominal tension, inhib-ited or excessive urination, early morning diarrhea.

Symptoms associated with depression: In addition to the symptoms for kidney qi vacuity above, the person will be extremely exhausted and will lack spirits.

Treatment principles: Nourish the kidney and warm yang.

Pulse: Deep and fine in the first (chi/foot) position.

Tongue: Pale, fat, with a thin, moist coating.

Main acupuncture points: UB 23, UB 52, Du 4, Ren 6, Kd 3, Kd 7. Moxa is applicable.

Special considerations: Kidney vacuity is rarely seen alone in clinical prac-tice; rather, it commonly combines with spleen qi vacuity to create the pattern spleen—kidney dual vacuity.Yang causes transformation and change; it activates and moves, and grants us the capacity to react and respond. Constitutional insufficiency, enduring disease, aging, and overwork can all lead to yang becoming vacuous. Kidney is the root of both yin and yang, providing the foundation of our life and the source of both yin and yang for all the other organs.Yang vacuity can therefore lead to vacuity of the yang of the spleen; conversely, long-standing spleen qi vacuity will lead to a deple-tion of kidney yang. Yang is like the fire under a kettle, if the fire is insufficient, the water in the kettle will tend to stagnate, creating a state of sogginess, congestion, inactivity, and a feeling of being frozen. Depression characterized by spleen—kidney dual vacuity will manifest as exhaustion, lack of will power and initiative, as well as hopelessness. Prolonged fear, shock, and guilt may all injure the kidney and cause this condition; but yang vacuity due to other causes can also result in fear and guilt.

Yin repletion: dampness and phlegm Spleen vacuity, dampness accumulating

Disease causes, disease mechanisms: Due to constitutional insufficiency, chronic disease, faulty diet, overwork and too much stress, too much think-ing and worry, the spleen qi may be insufficient to transport and transform liquids. It is also possible for external dampness to invade the body, causing damage to the spleen.

Main symptoms: Edema, dizziness, headache, fatigue, chest and epigastric fullness, and oppression, nausea, vomiting, diarrhea with white mucus: frequent but scanty urination; a slimy, sweet taste in the mouth.

Symptoms associated with depression: In addition to spleen qi vacuity symptoms above, mental confusion will be more severe and obsessive thinking will be more pronounced.

Pulse: A soggy, fine, and wiry pulse or a slippery, relaxed pulse.

Tongue: A swollen, pale tongue, with teeth marks on its edges and a thin, slimy, white coat.

Treatment principles: Fortify the spleen and transform dampness.

Main acupuncture points: In addition to points used to fortify the spleen above, add Sp 5, Sp 9, Ren 9.

Yin repletion: dampness and phlegm

Phlegm confounding the (orifices of the) heart

Disease causes, disease mechanisms: This pattern in mostly due to spleen vacuity and dampness engendering phlegm plus liver depression qi stagnation resulting in upward counterflow; the counterflow drafts the phlegm upwards causing mental confusion and disorientation.When such phlegm causes blockage of the flow of qi and blood to the heart, the spirit becomes much more upset. The spleen vacuity is due to a faulty diet, excessive worrying, overwork, and overthinking; the liver depression is due to anger and frustration. In addition, there may or may not be heart blood vacuity, further complicating the inability of the heart to house the spirit.

Main symptoms: Dizziness, excessive white phlegm, a feeling of oppression in the chest; no desire to eat, the sound of phlegm in the throat.

Symptoms associated with depression: Mental confusion, poor memory, withdrawal. lf severe, loss of insight and total mental confusion, obsessive thinking and rumination.

Pulse: Slippery and wiry, possibly bound.

Tongue: A thick, white, slimy tongue coating.

Treatment principles: Eliminate phlegm and open the orifices of the heart.

Main acupuncture points: St 40, P 5, P 6, P 7, LI 7, LI 4, St 25, Du 20, St 8. Additional acupuncture points: Add points that fortify the spleen, boost the qi, transform dampness, and rectify the qi.

Special considerations: This pattern occurs in several different diseases such as withdrawal disease and epilepsy. Traditionally, when this pattern refers to depression, it is characterized by severe mental confusion and dis-orientation, gradual appearance of abnormal behavior and dementia; this picture is more lil

Yin repletion: dampness and phlegm Heart vacuity, gall bladder timidity

Disease causes, disease mechanisms: Spleen vacuity causes, simultane-ously, dampness and phlegm on the one hand, and blood vacuity on the other. Because the spleen qi is weak, the blood is not produced sufficiently to nourish the heart spirit, which becomes restless; the heart and lung qi are also vacuous as a result of the spleen qi being weak.At the same time, there is liver depression qi stagnation and possibly counterflow.

Symptoms associated with depression: Difficulty making decisions, lack of courage and sense of direction in life, easily startled, susceptibility to fright and fear.

Pulse: Vacuous and weak, it may be slippery in the second (guan/bar) position. Tongue: Swollen and pale, moist coating.

Treatment principles: Warm the gall bladder, nourish the heart, and quiet the spirit.

Principal acupuncture points: GB 40, Ht 7.

Phlegm dampness obstruction and stagnation

Disease causes, disease mechanisms: The causes for this pattern are the same as those for phlegm obstructing the spirit. lf in addition following the path of the liver channel, the qi becomes bound in the chest, it affects the heart and lung and causes a feeling of oppression in the chest; if the qi accumulates and counterflows, it may cause a feeling of something being stuck in the throat. In this case, phlegm and qi loin and obstruce.

Main symptoms: A feeling of oppression in the chest or the feeling of something stuck in the throat that can be neither spat out nor swallowed down; the person may simply experience a feeling of constant postnasal drip. Excessive phlegm that is white in color and easily expectorated, nausea, possibly vomiting, fatigue, excessive desire to sleep, possibly vertigo and palpitations.

Symptoms associated with depression: Mental confusion, tendency to ruminate and obsessive thinking, irritability and frustration.

Pulse: Wiry and slippery.

Tongue: White, slimy tongue coat.

Treatment principles: Transform phlegm, disinhibit the qi, and resolve depression.

Main acupuncture points: St 40, P 5, P 6, P 7, LI 17, LI 4.

Additional acupuncture points: Ren 17, Sp 21, St 12, GB 17, GB 18.

Yin repletion: dampness and phlegm Phlegm fire harassing the heart

Disease causes, disease mechanisms: Basically the same as for phlegm obstructing the spirit (above), except for the addition of heat or fire arising from liver depression, qi stagnation.

Main symptoms: Emotional tension, heart vexation, agitation, red face and eyes, incessant talking, insomnia, bitter taste in the mouth, excessive or profuse yellow phlegm, chest oppression, constipation, aversion to food, burping, belching, acid regurgitation, possible nausea, vertigo, dizziness.

Symptoms associated with depression: Phlegm fire both mists and agi-tates the spirit. The phlegm aspect causes mental confusion, profound apathy and fatigue, poor memory; the fire aspect causes agitation, insomnia, anxiety, and in severe cases manic behavior.

Pulse: Wiry, large, rapid, slippery, possibly urgent.

Tongue: Crimson red with a thick slimy, yellow coat.

Treatment principles: Transform phlegm, clear heat, harmonize the stomach, and quiet the spirit.

Main acupuncture points: St 40, GB 15, L I, Lv 2, Ht 5, Ht 8, GB 18.

Special considerations: This mechanism is a further progression of the two mechanisms above. In this case, however, depression has endured long enough or is severe enough for liver depression to turn into depressive heat or fire.Thus there is phlegm blocking the orifices of the heart at the same time as there is fire disturbing the heart spirit. In this case, the person may alternate between periods of depression and confusion due to phlegm, and periods of abnormal elation or agitation, due to fire.This pattern, which when severe may correspond to manic depression, is very helpful in under-standing the disease mechanisms that precipitate depression. It is actually extremely common to find depressive heat concomitant with dampness and phlegm accumulation. The degree of liver depression, heat or fire, and dampness or phlegm varies widely; generally, people presenting with this pattern either alternate or experience simultaneously symptoms of damp-ness and phlegm, such as profound apathy and lethargy, and symptoms of heat and fire, such as anxiety and agitation. Phlegm dampness obstruction and stagnation, phlegm obstructing the orifices of the heart, and phlegm fire harassing the heart lie along a continuum of a series of patterns; these pat-terns derive from dampness accumulation due to spleen vacuity, in combi-nation with liver depression qi stagnation. Manic depression is a severe manifestation of this pattern, but unipolar depression accompanied by anxiety, agitation, and aggression may also be a result of this mechanism.

Additional comment on the dampness and phlegm patterns

The five depression patterns above are aggravated by faulty diet and emo-tional stress. Any food or drink that either damages the spleen or gives rise to more phlegm and dampness will make this disease mechanism worse. Similarly, any emotional stress or frustration mal

Blood/yin vacuity

Yin and blood vacuity are considered a continuum because blood is part of yin, with the exception that blood vacuity patterns do not in themselves give rise to heat.Therefore, one important differentiation between these two pat-terns is the presence or absence of heat.Yin vacuity and its effects on depres-sion depend on whether yin vacuity has given rise to vacuity heat. lf there is yin vacuity only, without vacuity heat, the spirit becomes weakened and the person feels depressed, tired, and dispirited; there is mental confusion and the memory and concentration are poor.When, in addition, there is vacuity heat as a result of yin vacuity, the spirit is not only weakened but is also unsettled; the person additionally experiences anxiety and mental restlessness.

Heart blood vacuity

Liver biood vacuity

Disease causes, disease mechanisms: Congenital insufficiency, chronic disease, aging, excessive blood loss, prolonged anger.

Main symptoms: Mild dizziness, numbness of the limbs, early insomnia (inabil-ity to fall asleep), blurred vision, floaters in the eyes, scanty menstruation or amenorrhea, brittle nails, muscle spasms or cramps, dull pale complexion.

Symptoms associated with depression: Depression with fatigue, lack of sense of direction, in life and ‘vision’, confusion about own aims, fear of making decisions.

Pulse: Thin, may be choppy.

Tongue: Pale and thin, with thin white coating.

Treatment principles: Nourish the liver and supplement the blood. Main acupuncture points: UB 17, UB 18, UB 20, UB 47, Lv 8.

Liver yin vacuity

Disease causes, disease mechanisms: Congenital insufficiency, overwork, excessive blood loss, aging, excessive sexual activity or anger, frustration and resentment over a long period of time can give rise to this pattern.

Main symptoms: Poor memory, dizziness; dry eyes, skin, and hair; blurred vision or night blindness, insomnia with restless, interrupted sleep, heat in the five centers, tidal fever, flushed cheeks in the afternoon, tremors or con-tractions of the sinews and muscles, numbness of the limbs, fragile nails, lateral costal pain; early, scanty, or painful menstruation.

Symptoms associated with depression: Deep depression with a lack of purpose in life, confusion about objectives and aims, restlessness.A sensation of floating before falling asleep.

Pulse: Floating and empty, or fast and wiry.

Tongue: Red tongue with no coat, or pale with red sides and tip.

Treatment principles: Nourish the liver, enrich yin, settle the hun, and quiet the spirit.

Main acupuncture points: UB 18, UB 47, Lv 8, Sp 6, Kd 3, Ren 4.

Additional points: Du 24, GB 13.

Blood/yin vacuity

Kidney yin vacuity

Disease causes, disease mechanisms: Constitutional insufficiency, age, chronic disease, overwork and prolonged emotional stress, excessive sexual activity, sequela of a febrile disease, excessive blood loss. Prolonged fear or guilt and sudden shock.

Main symptoms: Low back soreness and weakness, loss of hair, tinnitus or deafness, dizziness, low-grade afternoon fever, malar flushing, early mensiru-ation, uterine bleeding, amenorrhea. Insomnia with difficulty staying asleep.

Symptoms associated with depression: Depression with exhaustion, lack of willpower, feeling aimless; rigid mental attitude, restlessness, fidgety, despair.

Pulse: Deep, fine, and rapid.

Tongue: Red tongue, with a thin, yellow, scanty, dry or absent coating. Treatment principles: Supplement the kidney and enrich yin.

Main acupuncture points: UB 23, UB 52, Kd 3, Kd 6, Kd 14, Sp 6, Ren 4. Additional points: Kd 9, Kd 22, Kd 27.

Lung yin vacuity

Disease causes, disease mechanisms: Same as for kidney yin vacuity. Kidney yin vacuity and lung yin vacuity may give raise to each other or appear simultaneously. Lung yin vacuity may also be precipitated by sadness and grief.

Main symptoms: Same as for kidney yin vacuity, with the addition of dry cough with scanty phlegm, chronic low-grade sore throat, dry skin, with skin rashes.

Symptoms associated with depression: In addition to symptoms of kidney yin vacuity above, melancholy, sadness, and a tendency to hang on to the past nostalgically.

Pulse: Fine and floating.

Tongue: Red tongue with scanty coating.

Treatment principles: Supplement the lung (and kidney), enrich yin. Main acupuncture points: In addition to points for kidney yin vacuity, add UB 13, UB 42, Lu 9, Lu 5, Lu 7 (with Kd 6).

Yang repletion and vacuity heat

Liver depression transforms heat

As seen above, this pattern develops from liver depression qi stagnation, and is therefore described in full under that section.

Hyperactivity of liver yang

Disease causes, disease mechanisms: Kidney yin vacuity due to constitu-tional insufficiency, aging, long-term or severe disease, too much work, exces-sive sexual activity or sexual desire may give rise to hyperactivity of liver yang or ascendant fire. Anything that speeds up the body or pushes the body to prolonged excessive activity may lead to yin vacuity and yang hyperactivity, such as caffeinated drinks, recreational drugs, and too much exercise.Any of these can waste yin and stir yang hyperactively. Enduring stress may cause prolonged liver depression to transform into heat; this heat may eventually consume blood and body fluids, and damage yin. Depleted yin becomes unable to control yang, and yang counterflows upward, with symptoms of heat and repletion above and of cold and vacuity below.

Main symptoms: Headache, dizziness, vertigo, tinnitus, low back ache. Symptoms associated with depression: Pronounced irritability, palpita-tions, insomnia, and anxiety.

Pulse: Wiry and rapid.

Tongue: Red.

Treatment principles: Pacify the liver and subdue rebellious yang; clear heat, quicken the blood, supplement and boost the liver and kidney.

Main acupuncture points: GB 20, Lv 2, Lv 3, LI I I ,Yintang.

Additional acupuncture points: Sp 6,TH 5, GB 43, Kd 3.

Special considerations: In depression, this pattern rarely occurs on its own. Generally, one encounters anxiety, agitation, and severe insomnia as manifestations of yin vacuity, fire effulgence, concomitant with spleen qi, kidney yang vacuity (spleen—kidney dual vacuity); the latter gives rise to dampness and phlegm, which precipitates some of the apathy, lethargy, and anhedonia characteristic of depression.

Yang repletion and vacuity heat

Liver fire flaming upward

Disease causes: Emotional stress, frustration, and anger may cause endur-ing liver depression, which transforms into heat. lf this heat becomes exac-erbated it can turn into fire and flare upward, affecting the Iiver and its associated channels and network vessels. Overeating hot, greasy, and fatty foods, and alcohol, can give rise to dampness, which precipitates downward to the liver channel and causes damp heat in the lower burner; the heat may also draft the dampness upwards in the form of phlegm, obstructing the heart and agitating the spirit.

Main symptoms: Red face and eyes, bitter taste in the mouth, dry mouth, headache, dizziness, tinnitus and deafness, scorching pain on the ribs.

Symptoms associated with depression: Very angry, prone to outbursts of anger, impatience, restlessness, irritability; insomnia with violent dreams, vex-ation, and agitation. lf the anger is harbored inside for many years, this may lead to depression, which looks like sadness and grief, but is in fact anger.

Pulse: Rapid and forceful, or rapid, slippery, and wiry.

Tongue: Red with a slimy yellow coat.

Treatment principles: Clear the liver and drain fire, quiet the spirit, and settle the hun.

Main acupuncture points: Lv 2, IN 3, UB 18, Sp 6, Du 18, Du 24, GB 13, GB 15.

Additional acupuncture points: Ht 5, Ht 8.

Yang repletion and vacuity heat

Yin vacuity, fire effulgence (vacuity heat)

Disease causes, disease mechanisms: ff, as a result of constitutional insufficiency, aging, enduring disease, overtaxation or excessive sexual activity, yin becomes insufficient, it may be unable to control yang, and therefore fire counterflows upward. In this case, the fire stems from yin vacuity and is severe.

Main symptoms: Night sweats, tidal fever, heat in the five centers, increased sexual libido, heart palpitations, malar flush, dizziness, tinnitus, fre-quent urination, with scant, yellow urine; red lips, dry throat; vertigo and dizziness; possibly seminal emission in men and irregular periods in women.

Symptoms associated with depression: Fearfulness, anxiety, restless-ness, insomnia, heart vexation, easy anger, symptoms worst in the evening, fidgetiness, hypersensitivity.

Pulse: Fine, rapid, and possibly floating, specially in the first (inch/cun) position.

Tongue: A red tongue with scanty yellow coating.

Treatment principles: Enrich yin, clear heat or drain fire, settle the heart, and calm the spirit.

Main acupuncture points: UB 23, Kd 3, Kd I 0, Sp 6.

Additional acupuncture points: Ht 6, SI 3.

Special considerations: The patterns hyperactivity of liver yang, yin vacuity—fire effulgence, vacuity heat or fire, and yin vacuity—heat effusion (not mentioned here) are all variations of a basic disease mechanism in which there is insufficiency of yin, and repletion of heat or fire due to or exacerbated by this insufficiency.Yin vacuity originates from the kidney and may affect the other viscera and bowels; the heat or fire may arise from the liver, the heart, or the stomach and consume yin; alternatively, it may arise from the yin insufficiency itself, and flare upwards or exacerbate an under-lying accumulation of heat.

Yang repletion and vacuity heat Spleen vacuity giving rise to fire (yin fire)

Disease causes, disease mechanisms: Overthinking and worry, over-working, faulty diet and poor eating habits damage the spleen; if the spieen fails to control transportation and transformation it gives rise to dampness which percolates downward and damages the liver and kidneys. Dampness accumulation often transforms into damp heat. Dampness damages the kidney yang and the heat of damp heat tends to float upward; yang loses its root in its lower source (kidneys) and also tends to surge upwards

Main symptoms: Fatigue, lassitude of the spirit, weak extremities, lower back ache, low sexual desire, incontinence of urine, cold extremities, possibly unusual vaginal discharge or genital itching, turbid urination.

Symptoms associated with depression: Sorrow, inexplicable weeping and crying, agitation, anxiety, and insomnia.

Pulse: Large. slippery, floating, and rootless, especially in the first (cun/inch) position.

Tongue: Swollen. tooth-marked, dark hue, thicker yellow coat in the back, red tip.

Treatment principles: Supplement the spleen, transform dampness, rectify the qi, and clear heat.

Main acupuncture points: Ren 4, Ren 6, Ren I 5, UB 20. UB 23, Sp 9. Sp 6. Ht S.

Additional acupuncture points: Depend on the specific presenting signs and symptoms.

Special considerations: This pattern is a result of the complex mecha-nisms known as yin fire.Yin fire is different from vacuity heat (effulgent fire due to yin vacuity).Yin fire is a condition where yin cold and dampness are generated by a damaged spleen. Due to overthinking and worry. over-working, or faulty diet and eating habits, the spleen fails to controi trans-portation and transforrnation.The turbid portion of foods and liquids is not separated from the clear, and this becomes damp turbidity.This damp tur-bidity, which is yin, percolates downward, damaging the liver and kidneys. Because the host qi of the body is yang, yang turbidity often transforms into damp heat; dampness damages kidney yang, and both the heat of damp heat and the yang of the kidney tend to float and surge upwards. Usually there are syrnptoms of cold (and possibly also damp heat) in the lower body, as well as symptoms of heat in the upper part of the body, with other symp-toms manifesting as weakness of the spleen. ln the case of depression, this fire can either disturb the lungs giving rise to sorrow, inexplicable weeping, and crying. or it can disturb the heart giving rise to agitation, inappropriate laughter, and insomnia. This heat can also affect the stomach, precipitating insomnia and in severe cases manic symptoms.

The 12 Main Basic Patterns and Pattern Combinations

Basic patterns and pattern combinations

I. Liver depression qi stagnation

Liver depression transforms heat (including depressive heat affecting the heart and lung)Liver qi stagnation affecting the heart and lungLiver stagnation and stasisHeart—spleen dual vacuity (heart blood—spleen qi vacuity)Spleen—kidney dual vacuity (spleen qi—kidney yang vacuity)Phlegm confounding the orifices of the heartHeart vacuity, gall bladder timidityPhlegm dampness obstruction and stagnation

I O. Phlegm fire harassing the heart I I. Yin vacuity, fire effulgence

12. Spleen vacuity giving rise to fire

Points, Point Combinations, and Their Use in Major Depression

Patterns of disharmony rarely, if ever, happen on their own. Clinically, a combination of two or more patterns forms a complex web of inter-actions and interrelations. In depression, the combination of patterns incorporates elements of the four features on which this framework is based: (1) qi stagnation, (2) shen disturbance (vacuity or repletion), (3) vacuity of qi/yang and/or repletion of dampness/phlegm, (4) vacuity of yin/blood and/or repletion of heat/fire.

To arrive at a set of treatment principles and develop a treatment strategy, the patterns of disharmony involved, as well as their interac-tions and interrelations, must be identified. This is where the skill of the practitioner comes into play: to weave all the pertinent informa-tion into a complete symptom picture and, with this information, develop a treatment approach.

The assessment questionnaire developed for the study (see Appendix A) outlines the main symptoms for each pattern; because it is not a linear process, some overlap and some omissions are inevitable. The qualified practitioner takes this information to create a pattern of disharmony, and then uses this pattern as a guideline to develop a treatment protocol. The rationale for arriving at a particular treatment strategy needs to be outlined clearly. This is essential so that the practitioner can evaluate treatment progress; if the treatment fails, it will help the practitioner to determine why it may not be yielding the expected results. It is also important for allowing other practitioners to follow the rationale and assess the suitability of the diagnosis and treatment.

For example, assume a client presents with depression character-ized by depressed mood with both irritability and lethargy. Additionally she experiences breast distension, premenstrual exacer-bation of emotional lability, edema and fatigue after eating, insomnia with an inability to fall asleep, and an increased desire to sleep during the day; her pulse is wiry but also soggy in the second position on the right, and her tongue is swollen, pale, with darker sides and a red tip.

The first step involves differentiation of signs and symptoms:

n depressed mood with both irritability and lethargy: liver depression qi stagnation, spleen qi vacuity

n breast distension, premenstrual emotional lability: liver depression qi stagnation

n edema and fatigue after eating: dampness accumulation due to spleen vacuity

n insomnia with an inability to fall asleep: heart blood vacuity

n increased desire to sleep: qi vacuity, dampness accumulation

n wiry pulse: liver depression qi stagnation

n soggy pulse in the second right position: spleen qi vacuity

n puffy pale tongue: spleen qi vacuity, blood vacuity

n darker sides of tongue: liver depression qi stagnation

n red tip of tongue: shen disturbance due to heat agitating the heart.

Second, identify the pattern(s) of disharmony. This combination of signs and symptoms points to liver depression qi stagnation, heart—spleen dual vacuity, dampness accumulation due to spleen vacuity.

Third, establish the treatment principles. Course the liver, rectify the qi, and boost the qi, strengthen the spleen, nourish the heart (and blood), and calm the spirit.

Finally, select the points:

n to course the liver, rectify the qi: LV 3 and LI 4

n to boost the qi and strengthen the spleen: Ren 4, St 36, UB 20, SP 6

n to nourish the heart and calm the spirit: UB 15, Ht 7, P 6.

A first treatment, then, might include the following points: Lv 3 bilateral, LI 4 on the right, P 6 on the left, HT 7 on the left, Ren 4, ST 36 bilateral, Sp 6 bilateral.

The decision to needle the points contralaterally’ instead of bilater-ally is made on the basis of the clinical findings (signs and symptoms, tongue, pulse). The treatments and the sequence of treatments throughout the sessions are selected on the basis of severity and number of symptoms for each category (i.e. qi stagnation, shen disturbance, qi vacuity), as well as on the basis of an understanding of the disease mechanisms that precipitate specific patterns. Points are selected for their specific actions and their most effective combinations.

The points listed under each pattern above are given only as guidelines to address the treatment principles. To design successful treatments, one must choose from the lists of points and create effective point combinations, which address the specific pattern interactions for each client. The point functions and indications are based on The Practice of Chinese Medicine (Maciocia 1994).

Within the parameters of a research study, and in order to facilitate reliability and replica bility, clear guidelines must be established in the selection of points. Furthermore, needling techniques must be stan-dardized and consistent (neutral stimulation being the most easily replicable technique in a research setting). Without the additional benefit of specific needling techniques, effective point combinations are even more essential. The guidelines for point selection and needling techniques must allow the practitioner sufficient flexibility to provide an individually tailored treatment, while keeping in line with the stated framework.

In our research protocol, neutral stimulation and standard angle insertion (Xinnong 1987) were selected; needles were retained for 20 minutes, unless otherwise specified. Assessing acupuncturists (who design the treatment plans) were asked to adhere to the list of points and not to add points or combinations not included in the manual.

Because of the nature of the study design, which involved separat-ing the assessment from the treatment, the assessing acupuncturists

‘The term contralaterally, when used in this text, implies a point used unilaterally in relation-ship to another point needled on the opposite side as well as the opposite extremity, e.g. a point on the left foot needled in conjunction with a point on the right arm.

were asked to design a series of treatments to be used over time (8 weeks). These series needed to address effectively the complete set of treatment principles for treating the pattern combination and disease mechanisms appropriate for each person. For this reason, guidelines for point combinations, as well as guidelines for designing treatment progressively over time, have been outlined.

To design the most effective treatments there are four factors that must be taken into consideration in the selection and combination of points, which are described more fully in Maciocia (1994):

The dynamics of the flow of qi in the channels (according to their position and dynamics within the channel system)The energetic action of the point (their particular action, function, nature, or quality)The combination of points from different channels (to address the complex pattern combination and disease mechanisms)The area of the body affected by the point. The Dynamics of the Flow of Qi in the Channels

It is important always to balance local and distal, upper and lower, left and right. Later on, the use of specific guidelines in combining points following our protocol will be described in detail.

Local and Distal

Local points (L) include the head and trunk. Distal points (D) include the arms below the elbows, and the legs below the knees.

Upper and Lower

Upper points (U) include the arms, and lower points (L) include the legs; the combination of upper and lower points allows the balance of yin—yang channels, greater units (taiyin, shaoyang, jueyin), etc.

Left and Right

This is an extremely important tool that allows us to create dynamic treatment strategies. Maciocia (1994) says that needling points contralaterally is ‘like applying a force to the tangents of two opposite poles of a circle, making it spin’. Seem (1985) describes it as setting in motion the flow of qi in the channels in an infinite (.0) pattern. Points can be combined and needled contralaterally.

Strengthens the spirit.

Treats slight anxiety, insomnia, and depression.

Stimulates intelligence, and clears the mind.

Calms the mind, settles the hun.

To treat anxiety, mental restlessness due to liver disharmonies.

Calms the spirit, settles the po.

Releases emotions constraining the po in the chest and causing a feeling of oppression or tightness in the chest.

Can be a very calming point, especially in conditions due to vacuity.

Calms the spirit, relieves anxiety, insomnia, and mental restlessness.

Strengthens the willpower and calms the spirit. Roots the spirit in the kidney,`grounding’ it. Used to treat anxiety and mental restlessness in kidney vacuity.

Calms the spirit, settles the hun; gathers essence to the head.

Relieves severe anxiety and mental restlessness due to liver disharmony. Reduces jealousy and suspicion. Improves mental clarity due to injury of the hun by sadness.

As described above, enhances its calming effect.

Calms the spirit in severe anxiety due to heart disharmony.

Calms the spirit, settles the hun.

Reduces emotional fluctuations and obsessive thinking.

Calms and clears the spirit.

Stimulates memory and concentration.

Settles the hun and po, and stops obsessive thoughts.

Physically stimulates the dispersing and descending of lung qi and opens the nose.

Strengthens the willpower and the spirit. Bolsters the capacity to make decisions.

Calms and nourishes the spirit.

Specially indicated in heart blood and heart yin vacuity.

Calms the spirit, lifts mood, relaxes the chest. Rectifies the qi. Specially indicated for emotional problems associated with qi stagnation.

Settles the hun and calms the spirit when they are affected by anger, resentment, or frustration.

Releases constrained emotions in the chest, with a feeling of oppression or tightness. Has an outward movement, moves the qi, resolves stagnation, and ‘opens’ the spirit.

Opens yin wei mo, nourishes blood, relaxes the chest, calms the spirit, and settles the hun.

Strengthens its qi rectification action in emotional problems from repressed anger.

Lifts the mood, clears the spirit, relieves depression.

Lifts the mood, clears the spirit, opens the heart orifices, and relieves depression.

—To enrich yin further and clear vacuity heat: Ht 5—KD 6

—In addition to relieve oppression in the chest (very calming point combination): Ht 7—KD 9

—To clear heat further from the heart (depressive, replete, or vacuity heat): Ht 5—KD 9

n To harmonize Jueyin (Lv/Per), regulate qi, open the chest, resolve depression, release suppressed emotions, and settle the hun: Lv 3—P 6

—In addition, to calm the spirit and/or eliminate phlegm and open orifices of the heart: Lv 3—P 7

—To regulate the descending of Lu/Ht qi, clear depressive heat affecting the Ht/Lu, settle the heart, and calm the spirit: Lv 3—P 4

n To course the liver, rectify the qi, resolve depression, calm the spirit, settle the ethereal soul, and regulate the ascendance and descendance of qi: Lv 3—LI 4 (Note: Avoid this combination during pregnancy.)

n To regulate the middle burner, subdue counterflow qi, resolve phlegm, calm the spirit: P 6—St 40

—In addition, to open the orifices of the heart add: GB 18

—In addition, to clear heat and drain fire from the heart add: Ht 5, Ht 8

—In addition, to clear heat: P 5—St 40

n To regulate the middle burner and subdue counterflow qi, con-comitant with spleen—stomach vacuity: P 6—St 36

n To strengthen memory and concentration due to spleen—heart dual vacuity: Ht 5—Sp 3

n To nourish the heart, calm the spirit, and open the orifices of the heart. To assist decision-making by discriminating between choices: Ht 7—SI 5

n To course the live; rectify the qi, settle the ethereal soul, when dis-tension combines physically with emotional moodiness and depres-sion: Lv 3—GB 342

n To fortify the spleen, boost the qi, and nourish the blood: St 36— Sp 6 (Note: Needle both points bilaterally.)

n To course the liver, rectify the qi, and resolve depression, when it causes chest oppression and sighing: P 6—TH 6

n To course the live; rectify the qi, open the orifices of the heart, calm the spirit, and lift the mood, when the patient presents with mental confusion and depression due to long-standing emotional problems and suppressed emotions: P 6—TH 3

n For the same indications as the previous combination, with a more calming effect: P 7—TH 3

n To course the liver, rectify the qi, calm the spirit, resolve counterflow qi headaches, neck tension due to emotional problems: P 6—TH 4

n To nourish the heart, calm the spirit, and strengthen the gall bladder’s capacity to make decisions: GB 40—Ht 7.

According to the Areas of the Body Affected by the Points

When selecting distal points, it is important to consider the area affected by the point, in addition to considering the action of the points or the dynamics of the flow of qi in the channels (Maciocia 1994). The general principle is that the further the point is along the channel, the further its influence is exerted; this is true only for the points on the arms and the legs, which affect the upper extremity of the channels. For a detailed overview of the areas affected by the principal channel points, see Maciocia (1994).

It is traditionally stated in Chinese Medicine that acupuncture should be performed conservatively during pregnancy in order to minimize the possibility of inducing miscarriage or precipitating premature labor. If performed judiciously, knowledgeably, and with care, however, it can be extremely beneficial as a remedial treatment for a number of problems that may arise during pregnancy, including depression. Caution must be employed to avoid any points forbidden during pregnancy, unless they clearly readdress a complication of pregnancy (Flaws 1983). The application of this framework in research protocols during depression in pregnancy should avoid the following points:

With needle LI 4, Sp 1, Sp 6, GB 21, UB 60, UB 67, Ren 3, 4, 5, and 6 With moxa LI 4, Sp 2, Ren 3, 4, 5, and 6

In addition, the following points are advised against: St 36, St 45, UB 23, UB 32, Kd 4, GB 44, Lv 1 (moxa).

These points either directly or indirectly create a lot of movement in the pelvic cavity, and some affect the uterus specifically; they can potentially create an unnecessary stirring of the fetus, which could lead to miscarriage or premature labor. Many of these points are in fact used to promote labor.

7. Design treatment plans to address over time (the entire duration of the treatment; i.e. 8 weeks,) all the treatment principles out-lined in the pattern differentiation (based on the presenting signs and symptoms, constitution of the patient, rate of severity, previ-ous history of depression, etc.).

8. During the first 4 weeks of treatment emphasize coursing the liver, rectifying the qi, transforming dampness and phlegm, clearing heat, calming the spirit, etc., and secondarily treat the underlying vacuity. After that, focus on fortifying the spleen, boosting the qi, nourishing the heart, supplementing the kidneys, etc., while continuing to address the other disease mechanisms.

9. In menstruating women, emphasize coursing, rectifying, trans-forming, and clearing in the 2 weeks preceding the menstrual cycle. Focus on boosting, supplementing, nourishing, and fortify-ing in the week after the period. During menstruation it is best to continue with the premenstrual strategy, except towards the end of the period.

Use mu points and other points on the ventral aspect of the body for the first 2 weeks and then use shu points. Use the points on the outer line of the UB channel, after having addressed the main patterns, on both the ventral and dorsal aspects of the body (around week 4, treatment 7).Use a total of seven acupuncture points and three auricular points. Select the seven acupuncture points from a set of five main points that together address the appropriate combination of the four main features: (1) liver depression qi stagnation, (2) shen disturbance due to vacuity or repletion, (3) vacuity of qi—yang/blood—yin, and/or (4) repletion of dampness—phlegm or hyperactivity of yang.

b. Select at least one of the two remaining points to regulate the du channel or directly affect mental functions (i.e. Du 24 or GB 18), and the other point to address the pattern differentiation further.

Select three auricular points from the list provided, based on the Auriculotherapy Manual (Oleson 1992), to further address damage by the emotions.

d. The treatment course consists of 12 acupuncture treatments given over an 8-week period, biweekly for the first 4 weeks and weekly during the next 4 weeks.

In the protocol presented here, after conducting an assessment with the four evaluations, the presenting signs and symptoms are differen-tiated on the basis of the four features as detailed below. It is also necessary to assess the specific viscera and bowels involved.

Liver Depression Qi Stagnation

The level of liver depression qi stagnation is evaluated, as are the level of heat transformation and the degree to which the stagnation may be affecting either the heart or the lung. Points are then chosen to course the liver and rectify the qi, clear heat, calm the shen, and assist in descending lung qi accordingly. In menstruating women, mood and symptom changes related to the menstrual cycle are considered impor-tant factors because of the liver’s effect on the movement of blood. Premenstrually, emphasis is placed on coursing the liver, rectifying the qi, and clearing heat, as appropriate (i.e. treating the repletion caused or aggravated by stagnation). Postmenstrually, emphasis is placed on supplementing vacuity. This is based on the understanding that reple-tion symptoms typically manifest before menstruation and vacuity symptoms manifest after menstruation. As explained in the section on the menstrual cycle, yang begins to grow during the third week of the cycle, and qi and blood are both at their maximum in the week pre-ceding menstruation. The blood becomes relatively empty as part of the process of menstruation, being most vacuous at the conclusion of the period (Flaws 1992). Again, we determine to what extent the stag-nation has transformed into heat (repletion of yang), whether it has given rise to blood stasis, or whether it has caused dampness and phlegm to accumulate. We believe that this information can poten-tially help to predict outcome and relapse, based on the hypothesis that the greater degree of blood stasis and phlegm accumulation, the lower the rate of remission and the higher the incidence of relapse, given acupuncture treatment alone.

Shen Disturbance

The nature and degree of shen disturbance is examined to determine whether it is due to vacuity (heart blood, heart qi, or heart yin vacuity with or without vacuity heat) or to repletion (qi stagnation, or depres-sive heat affecting the heart, or phlegm confounding the orifices of the heart, with or without heat or fire). Points are then chosen to nourish the heart, calm the shen, and/or clear heart, drain fire, transform phlegm, and open the orifices, as needed.

Vacuity and Repletion

The way in which liver depression qi stagnation and shen disturbance combine with, exacerbate, or precipitate tendencies towards vacuity of qi—yang and/or blood—yin is analyzed. Additionally, the extent to which dampness and phlegm accumulate (repletion of yin), and the extent to which yang becomes replete (hyperactive liver yang, liver fire, or vacuity heart), is also evaluated. Points are then chosen to supplement vacuity of qi—yang and/or yin—blood, and/or to transform dampness and phlegm, clear heat, drain fire, etc., in order to regulate yin and yang based on the presenting signs and symptoms.

Viscera and Bowels

The involvement and role of each viscus and bowel and the functional interactions among them are analyzed. On one hand, special attention is paid to how the mechanisms of depression affect each one of their functions. On the other hand, the extent to which their dysfunction precipitates this particular depression episode is also determined.

Channels and Network Vessels

The 12 regular channels plus du mai, ren mai, and chong mai are the only channels used in our protocol. To regulate the flow of qi, stimu-late brain function, and clear the heart’s orifices, the use of points along the du channel is emphasized. To help refine point selection, the use of palpation of both the channels and the abdominal area is encouraged. Additionally, the concept of the six great units as consti-tutional predispositions (based on Yves Requena’s eight diatheses (Requena 1986) has been used as a diagnostic tool; the six great units have also been used as guidelines for effective point combinations.

The Five Phases

The precipitating factors, the nature of the depressive episode, and the constitutional predisposition of the patient are analyzed by using the five phases as a framework. Primarily, Denmei’s (1990) concept of constitutional types as predisposing factors, Beinfield & Korngold’s (1991) five phases as types, and the classic five phases correspondences (Maciocia 1989) have been used.

In our protocol, the last two theories have been used exclusively to refine our understanding of the constitutional tendencies of each individual. These theories are used in order to design more effectively a treatment strategy that would address both circumstantial manifestations and

trait tendencies. We believe that by using the five phases and the six units extensively as reframing tools, in both assessment and patient education, we gain the ability to capture the complexity of interaction between trait and circumstantial tendencies, between the branch and the root.

It would be well beyond the scope of this manual to present in detail any of those two theories. The interested reader is invited to consult the sources cited in the References for an indepth overview of the use of the six units and the five phases in diagnosis.

Implementation of the Assessment Framework

After using conventional Western assessment techniques to diagnose major depression and to exclude other relevant conditions, we perform a differential diagnosis on all participants entering treatment. The differential diagnosis is accomplished by using the traditional method of the four evaluations (Kaptchuk 1983, Maciocia 1989). The basic procedure is as follows.

Questioning

First, a questionnaire is administered (see Appendix A). In the first section, we ask about the precipitating factors, previous history of depression, and the person’s unique experience of being depressed. We aim at getting a clear sense of the person’s constitutional tendencies, the psychosocial nature of their depression, and how their lifestyle has influenced their health. It is in this section that we make the most use of the six great units, the five phases, and the eight principles, to under-stand constitutional tendencies. In the second section of the question-naire, we focus on differentiating the symptom criteria for major depressive episode (DSM-IV) on the basis of our theoretical framework; special attention is paid to how the symptom criteria correspond to liver depression, qi stagnation, shen disturbance, and vacuity or repletion of yin and yang. During the interview, the assessors probe the questions in detail, to differentiate disease mechanisms and pattern combinations clearly. For women, we take an indepth gynecological history, including menstrual cycles, pregnancies, etc. We conclude by inquiring about the emotional nature of the patient’s complaints and the current specific manifestations of the depression.

Palpation

Pulses are taken in the traditional fashion, as detailed in The Secret of Chinese Pulse Diagnosis (Flaws 1995). The main pulse definitions employed can be found in Appendix B. Additional information on pulse diagnosis is taken from Kaptchuk (1983) and Maciocia (1989).

We determine the pattern(s), treatment principles, and treatment strategy by emphasizing differentiation of signs and symptoms, and pulse and tongue evaluation, as traditionally performed in the eight principles model. We begin with the premise that liver depression qi stagnation and an inability of the heart to store the shen properly underlie the disharmony in most cases. We determine to what extent this is true and explore whether the stagnation is affecting other viscera, and whether the shen disturbance is due to vacuity or reple-tion disease mechanisms. Additionally, based on the information gathered, we assess to what extent the pattern is characterized by yang features (psychomotor agitation, dream-disturbed sleep, and irritability) and develops along the yin vacuity—yang repletion con-tinuum. Similarly, we determine the extent to which the pattern is characterized by yin features (psychomotor retardation, fatigue, hypersomnia) and develops along a vacuity of qi—yang/repletion of yin continuum. The involvement of each viscus and bowel is analyzed as well.

The following is a summary of the approach:

1. The acupuncturist performs a Chinese Medicine assessment using the intake form (provided in Appendix A) as a guide to gather information about the signs and symptoms, inquiring verbally about problem areas.