Outburst on Depression
Outburst on Depression
I find myself often musing on the myriad reasons for such a high number of folks on antidepressants. It seems Aldus Huxley was really talking about Prozac, not soma, in the futuristic Brave New World. Is one reason misinterpretation of depression and a continued societal intolerance of moods and feelings? Somehow, if you are not happy at least 85% of the time, you are depressed and need treatment. Are acupuncturists helping to heal these soul wounds, or helping to "promote" the label of depression?
During the educational process, the acupuncturist will often be exposed to the word "depression." In the teaching of shen disturbance words like anxiety, psychosis and schizophrenia will get bandied about; although, I think "depression" is the one condition that gets misused the most. Misuse of the label "depression" by natural healers, acting in their position of authority, could be contributing to the epidemic that depression has become in our culture. In fact, they may even be supporting the very pharmaceutical companies they wish to replace.
How many of us really know what depression is, and by that, I mean medical depression? Most of our patients do not know the difference between a prolonged, uncomfortable, sad feeling and the actual clinical state of depression. How many times during your clinical training did you hear a supervising doctor announce the patient has depression, or even have the patient tell you this diagnosis? I have certainly heard it and continue to hear it far more often than simply, "I've been feeling very sad lately." Not often on referral or in CEU seminars do I hear, "the patient was prone to sorrow, or melancholy, etc." If we do not know the difference, our patients will likely never be enlightened and may even adopt the label permanently. Depression as a diagnostic label has much power; just think of how much power the word cancer has. When a person gets committed to their label, the condition is often much harder to treat, leading them down the chemical path to Prozac.
The Chinese teachers in America have a difficult task translating an experience such as melancholy, sadness, apathy, lethargy, disillusionment, grief, sorrow or, heaven forbid, depression. One reason for this may be due to the absolute reductionism that occurs when translating Chinese characters into English language. Or perhaps the cultural differences regarding the expression and verbalization of strong emotion have much to do with with the lack of distinction when describing a "depressive" shen disturbance. A final option, the teachings of Chinese medicine with regard to the shen are just that, Chinese medicine teachings. They are not western psychology. However, your patients are generally western, accustomed to expressing emotions (though we still repress far too much), and depression is very different from sadness, grief, apathy, etc. Unless you truly understand depression and its vicissitudes you would be much better off asking your patient if their shen is disturbed than if they are depressed.
Now that we have justified why this may be a problem, what to do? Most of us spend time discussing emotions with our patients, and "lifestyle counseling" is within the scope of our practice. I may be making a huge offensive assumption here. If so, I apologize; but most acupuncturists have had one tiny class in psychology, yet treat psychological illness all the time. Would you allow a surgeon to perform an operation on a disease he/she cannot differentially diagnose? That does not mean we all need a degree in psychology (Trust me. It's overkill!), but getting more information is essential. First, pick up a copy of the DSMIV, the Diagnostic and Statistical Manual of Mental Disorders. In it will be found many types of depression, the least serious being the "Major Depressive Episode." The requirements for this diagnosis include the following:
A. At least five of the following symptoms have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure. (Do not include symptoms that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence, or marked loosening of associations):
Depressed mood (or can be irritable mood in children and adolescents) most of the day, nearly every day, as indicated either by subjective account or observation by other,
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time),
Significant weight losss or weight gain when not dieting (e.g., more than 5% of body weight in a month, or decrease or increase in appetite nearly every day, and in children, consider failure to make expected weight gains),
Insomnia or hypersomnia nearly every day,
Psychomotor agitation or retardation nearly every day (observable by other, not merely subjective feelings of restlessness or being slowed down),
Fatigue or loss of energy nearly every day,
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick),
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others), and
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. 1) It cannot be established that an organic factor initiated and maintained the disturbance.
2) The disturbance is not a normal reaction to the death of a loved one. (Uncomplicated Bereavement)
Note: Morbid preoccupation with worthlessness, suicidal ideation, mared functional impairment or psychomotor retardation or prolonged duration suggest bereavement complicated by Major Depression.
C. At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms (i.e., before the mood symptoms developed or after they have remitted).
D. It is not superimiposed on Schizophrenia, Schizopheniform Disorder, Delusional Disorder, or Psychotic Disorder NOS.
Yeah, and that's just an episode. Actual Major Depression is two or more episodes separated by "at least two months of return to more or less usual functioning," this is also without any manic or hypomanic episode. Most of us think of depression in a way that is more like Dysthymia. Dysthymia is a depressive episode for two years without a remission of symptoms for more than two months, and lacking manic or hypomanic episodes. It is often difficult to distinguish between Major Depression and Dysthymia.
So, when a patient of mine says they are depressed, I don't jot that down, think liver qi stagnation and move on. I ask, "What does it feel like?" "Do you cry often?" "Are you feeling disillusioned and therefore apathetic?" "Are you anxious?" You get the idea. Then inquire how long they have been feeling these feelings and how constantly. Does the feeling interfere with their ability to work and be somewhat social? Was there an inciting incident before these feelings occurred? Then look in your intake form for the rest of the criteria. If it all comes together, then you have a clinically depressed person who is totally entitled to use the label if they wish.
If you do not find all the criteria, it is good to ask why the patient thinks these feelings are occurring. Is it in response to some specific stressor: a loss, death, bad week at work, poor test scores, relationship trouble? The list is endless in this day and age. If so, you may want to explain that the feelings they are having are appropriate to the stimulus that was provided. How should a person react after a loss? They may feel sadness, bereft, any number of descriptions for a feeling, not a clinical disease. Moods, feelings, and emotions are normal and their expression must be encouraged, not labeled and medicated, naturally or otherwise. A prolonged episode of these feelings can often be a call from the soul, a rich opportunity to explore the inner landscape and make life changing discovery. From a psychological perspective, depression itself may in part be caused by the person's inability to experience or express those emotions. Further, even the expression of a "negative" emotion like sadness or anger will actually increase the activity of the immune system. So, even for those New superstitiously Aged folk who may fear that feeling a negative emotion will create a negative reality....not so! It is the suppression and repression of emotion that promotes depression.
In closing, as we educate ourselves to diagnose a clinical psychological "disease," by all means treat their five element, zang-fu, eight principles diagnosis. Even addressing depression within the metaphoric framework of Chinese medicine is appropriate and may be advisable; but, we should refer the patient to a therapist/psychiatrist for the rest.
By Lynda M. Harvey