Seasonal Affective Disorder (SAD) is a type of depression triggered by external cues related to the changing seasons, particularly associated with the decrease in the length of the day during winter. While there may be a bit of stigma attached to the word "depression," Chinese medicine actually expects everyone to experience this, to some degree, during the winter months. The quintessential foundational text of Chinese medicine, the Su Wen, states:
The three months of winter are called the period of closing and storing. Water freezes and the Earth cracks open. One should not disturb one’s Yang. People should retire early at night and rise late in the morning and they should wait for the rising of the sun. They should suppress and conceal their wishes, as though they had no internal purpose, as though they had been fulfilled. People should try to escape the cold and they should seek warmth, they should not perspire on the skin, they should let themselves be deprived of breath of the cold.
There's a natural process of, for lack of a better term, hibernation that we go through in the winter, both physiologically and socially. Obviously it's colder, grayer, and darker in the winter, and we're pretty much done tending the crops for the year, so we tend to hold up in our homes near the fire and wait out the winter like hermits, so to speak. Sure, we still go out but much less than during the warmer months. The exception might be holiday gatherings, but these are traditionally done in the home, as well. Similarly, the Qi resides deeper in the body during the winter. It stays closer to the organs to warm them and encourage storage of vital substances, so there's much less outward expression of the Qi. The inherent characteristics of the winter season naturally work to subdue the emotions.
Depression from Depressed Qi
In the 18th century Za Bing Yuan Liu Xi Zhu (Wonderous Latern Peering into the Origin & Development of Miscellaneous Diseases), it says, "All depression can be classified as liver disease." The meaning here is that, although, like any condition diagnosed with Chinese medicine, there are a myriad causes, depression almost always has a component of Liver Qi stagnation (which is often referred to as "Liver depression" or "depressed Liver Qi"). Now, the thing with Liver Qi stagnation is that it has become such a commonplace diagnosis among acupuncturists that there's almost a gut reaction (for me and many of my colleagues, at least) to want to state that one cannot simply blame everything on Liver Qi stagnation. Something to keep in mind, however, is that the Liver, as the Wood element, is responsible for managing the orderly reaching (branching out) of Qi, as well as its coursing and discharge. The Liver keeps the Qi moving - through all the channels and vessels - so when that process is impeded or impaired, all systems and meridians are at risk for Qi stagnation. Many patients with depression present with stagnation of Qi in the Lung system, for example, but rather than being due to Lung deficiency and an inability to push the Qi with the Lungs, the stagnation comes from a loss of the Liver's ability to make Qi course throughout the entirety of the body, and so the Lungs become affected.
What causes Liver Qi stagnation? The most common causes are emotional factors: anger, frustration, stress, even depression. Yes, depression can cause the condition in the body that causes depression! That's why treatment is so important to break the cycle! Other causes include Blood deficiency, poor diet, too little exercise, and aging. With regard to depression, Bob Flaws emphasizes unfulfilled desires. He says in The Treatment of Western Psychiatric Disease with Chinese Medicine:
"All desire is the subjective experience of a movement of Qi towards something we want or away from something we don't want. When such desires remain unfulfilled, this inhibits the Liver's Qi mechanism. The Liver's Qi mechanism is responsible for coursing and discharge. This means the spreading and extension of the Qi. If the Liver's Qi mechanism becomes depressed, then the Qi becomes stagnant."
Pattern Discrimination
When a patient indicates that they want to address symptoms of depression, it is important to find out what depression means to them. We have a general sense of what depression is, at least in our own mind or own experience, and therefore an expectation that everyone else conceives of it that same way, but really each of us experiences depression in a different way. The specific symptoms (and even feelings) that accompany depression give us idea of what the mechanism of imbalance is. Many times, signs and symptoms that patients don't associate with their condition actually offer important clues, as well.
Here are some of the main patterns of depression we look for as described by Bob Flaws:
Feeling withdrawn, closed off, and depressed in the winter is normal and natural because the body is so heavily influenced by the environment and weather around it. However, these feelings should be mild to moderate and last only temporarily - otherwise, there's a little more going on than a natural physiological phenomenon. Since the Qi is already deeper, slower, more subdued, there is a greater potential for a pathological process to occur and for feelings of depression to increase beyond the typical winter blues.
In the 18th century Za Bing Yuan Liu Xi Zhu (Wonderous Latern Peering into the Origin & Development of Miscellaneous Diseases), it says, "All depression can be classified as liver disease." The meaning here is that, although, like any condition diagnosed with Chinese medicine, there are a myriad causes, depression almost always has a component of Liver Qi stagnation (which is often referred to as "Liver depression" or "depressed Liver Qi"). Now, the thing with Liver Qi stagnation is that it has become such a commonplace diagnosis among acupuncturists that there's almost a gut reaction (for me and many of my colleagues, at least) to want to state that one cannot simply blame everything on Liver Qi stagnation. Something to keep in mind, however, is that the Liver, as the Wood element, is responsible for managing the orderly reaching (branching out) of Qi, as well as its coursing and discharge. The Liver keeps the Qi moving - through all the channels and vessels - so when that process is impeded or impaired, all systems and meridians are at risk for Qi stagnation. Many patients with depression present with stagnation of Qi in the Lung system, for example, but rather than being due to Lung deficiency and an inability to push the Qi with the Lungs, the stagnation comes from a loss of the Liver's ability to make Qi course throughout the entirety of the body, and so the Lungs become affected.
What causes Liver Qi stagnation? The most common causes are emotional factors: anger, frustration, stress, even depression. Yes, depression can cause the condition in the body that causes depression! That's why treatment is so important to break the cycle! Other causes include Blood deficiency, poor diet, too little exercise, and aging. With regard to depression, Bob Flaws emphasizes unfulfilled desires. He says in The Treatment of Western Psychiatric Disease with Chinese Medicine:
"All desire is the subjective experience of a movement of Qi towards something we want or away from something we don't want. When such desires remain unfulfilled, this inhibits the Liver's Qi mechanism. The Liver's Qi mechanism is responsible for coursing and discharge. This means the spreading and extension of the Qi. If the Liver's Qi mechanism becomes depressed, then the Qi becomes stagnant."
Pattern Discrimination
When a patient indicates that they want to address symptoms of depression, it is important to find out what depression means to them. We have a general sense of what depression is, at least in our own mind or own experience, and therefore an expectation that everyone else conceives of it that same way, but really each of us experiences depression in a different way. The specific symptoms (and even feelings) that accompany depression give us idea of what the mechanism of imbalance is. Many times, signs and symptoms that patients don't associate with their condition actually offer important clues, as well.
Here are some of the main patterns of depression we look for as described by Bob Flaws:
- Liver Qi Stagnation will present with irritability, a tendency to sigh, taciturnity, solitariness, PMS, chest oppression and rib-side pain, lower abdominal distention and pain, diminished appetite, possible delayed menses which are painful and with darker blood. The tongue will be normal or slightly dark with a white coat, and the pulse will be wiry.
- Liver Fire is a pattern which occurs with prolonged or intense Liver Qi stagnation; where there is non-movement of Qi, heat builds up. It is the nature of fire to flare upward, so in addition to signs of Liver Qi stagnation, patients will also experience anger instead of just irritability, bitter taste in the mouth, possible acid regurgitation. The tongue will be red and have a yellow coat, and the pulse will be wiry and rapid. Often there will be headache, tinnitus, red eyes, dry mouth, dry stool and constipation, and outbursts of anger marked by shouting, cursing, and potentially violence.
- Phlegm Obstruction can occur when Liver Qi stagnation affects splenic function. Symptoms include "plum pit qi," a subjective feeling of something lodged in the throat that can neither be swallowed or expelled, classically described as feeling like a piece of roasted meat; oppression in the chest, possible rib-side pain. The tongue will have a slimy, white coat, and the pulse will be slippery or wiry and slippery.
- Heart Qi and Blood Deficiency means the Heart is not properly nourished, and so the spirit becomes restless or depressed. Patients will experience mental-emotional abstraction, restlessness, sorrow and anxiety, and a tendency towards crying. The tongue will be pale with thin, white coating, and the pulse will be thin and wiry.
- Deficiency of Heart and Spleen presents with excessive thinking with a tendency to worry, heart palpitations (which, when discussed in Chinese medicine, mean a subjective feeling or awareness of your heart beating within you chest), difficulty sleeping, impaired memory, lack of concentration or focus, lassitude of spirit, diminished interest in eating and drinking, and possibly weakness in the arms and legs. The tongue will be pale and possibly swollen, and the pulse will be thin and weak.
- Spleen and Kidney Yang Deficiency, according to Bob Flaws, doesn't usually present in its pure form with regard to depression may complicate patterns of Liver depression. It causes emotional listlessness and depression, a predilection to lie down, lack of desire for movement, fright and fear, heart palpitations, sleep loss, a somber facial complexion, decreased or absent libido, sexual dysfunction, low back soreness, and cold feet. The tongue will be swollen and pale with possible teeth marks on the sides, and the pulse will be thin and deep.
- Kidney Yin Deficiency with Heat presents with anxiety and depression, vexation and agitation, vertigo and dizziness, heart palpitations, insomnia, profuse dreaming, heat in the palms and soles of the feet, easy angering, low back soreness, menstrual irregularities, possible sexual dysfunction, aversion to people, and dry mouth and throat. The tongue will be dry and red with a scanty coat, and pulse will be thin and rapid.
Clinically, each of these patterns can and usually do present in combination with other patterns. As mentioned above, Liver Qi stagnation is almost always a factor, and phlegm and deficiency conditions are common as well. One of the most commonly used herbal formulas for mild depression, irritability, or stress (among many other possible uses) is generally considered to be THE formula for Liver Qi stagnation, but it actually functions as equal parts Qi-mover, Blood-nourisher, and Spleen-fortifier.
Treatment Strategies
The acupuncture and herbal treatments employed generally focus on coursing or invigorating Liver Qi but also on transforming phlegm and dampness or nourishing the Heart, Spleen, or Kidneys, depending on the pattern. Taking an herbal formula in particular, as always, is a great way to continue treating the condition on your own time.
Another great way to work on depression is exercise. Any intense physical activity that gets the heart rate up is perfect. That physical movement of the body moves the Qi - it literally jostles it loose and forces it to flow. Many people run or go to the gym as a form of stress relief, and this is precisely why it works so well. If you're not physically fit enough for Iron Man-level workouts, start slow and work your way up gradually. Tai Ji and yoga are great ways to move the Qi that are easily accessible at all levels of physical fitness. Even starting with a brisk walk around the neighborhood can be very helpful. Take advantage of sunny days during the winter. Sunlight exposure increase serotonin production and is believed to be a key factor in Seasonal Affective Disorder. Also, don't underestimate the power of fresh air! Motivation can definitely become an issue, so use acupuncture to help get over that initial hurdle!
Lastly, in addition to maintaining a healthy and balanced diet, there are certain foods which help to move the Liver Qi. Artichokes, beets, cilantro, cucumber, lotus root, parsley, turnip, grape, grapefruit, hawthorn berry, lemon, lime, and fennel are all good at moving the Qi. Avoid spicy, oily, and fried foods as they aggravate the Liver and encourage phlegm production.
Other foods to use are those which are considered fiery in nature and offer a good balance to the water season of winter.
From a Daoist 5-element perspective, fire is associated with the Heart which expresses joy as it's emotional. Cultivating the Qi of fire during the winter season helps to bring joy and alleviate seasonal depression. Eat foods that grow in the winter like asparagus and cabbages. Broccoli and cauliflower are also good. Red cabbage and brussels sprouts are particularly good because their leaves grow inward which reinforces their fire and Heart Qi-boosting properties. Consider roasting your meats and vegetables to further endow them with a fiery nature, and you'll cruise right through winter.
From a Daoist 5-element perspective, fire is associated with the Heart which expresses joy as it's emotional. Cultivating the Qi of fire during the winter season helps to bring joy and alleviate seasonal depression. Eat foods that grow in the winter like asparagus and cabbages. Broccoli and cauliflower are also good. Red cabbage and brussels sprouts are particularly good because their leaves grow inward which reinforces their fire and Heart Qi-boosting properties. Consider roasting your meats and vegetables to further endow them with a fiery nature, and you'll cruise right through winter. 