13/03/2025

Yu Zheng 郁证

EN-ACU2
Dr Dan Tan

What is Depression?
Depression, also known as major depressive disorder (MDD), is a common and serious mental
health condition that affects how a person feels, thinks, and handles daily activities.
It is characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure
in activities once enjoyed.
Other symptoms can include changes in appetite or weight, trouble sleeping or sleeping too much,
loss of energy, increased fatigue, feelings of worthlessness or guilt, difficulty thinking, concentrating,
or making decisions, and thoughts of death or suicide.

Depression can vary in severity from mild to severe and can affect people of all ages and
backgrounds.

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Part One:
Depression
in Western Medicine

1. Symptoms
2. Causes
3. Diagnosis
4. Treatment

1. What are the symptoms of depression?

▪ Persistent Sadness: A continuous feeling of sadness, emptiness, or hopelessness.
▪ Loss of Interest or Pleasure: A lack of interest or pleasure in activities once enjoyed, including
hobbies, social activities, and sex.
▪ Changes in Appetite or Weight: Significant weight loss or gain, or changes in appetite.
▪ Sleep Disturbances: Insomnia or excessive sleeping.
▪ Fatigue and Low Energy: Feeling tired and having a lack of energy, even after small tasks.
▪ Feelings of Worthlessness or Guilt: Persistent feelings of worthlessness, guilt, or self-blame.
▪ Difficulty Concentrating: Trouble thinking, concentrating, making decisions, or remembering
things.
▪ Physical Symptoms: Unexplained physical problems, such as back pain or headaches.
▪ Restlessness or Irritability: Feeling restless, agitated, or easily annoyed.
▪ Thoughts of Death or Suicide: Recurrent thoughts of death, suicidal ideation, suicide attempts, or self-
harm.
Note: These symptoms must be present most of the day, nearly every day, for at least two weeks for a
diagnosis of depression.

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2. What are the causes of depression?

The causes of depression are complex and multifactorial, involving a combination of genetic, biological,
environmental, and psychological factors. Here are the primary factors that can contribute to the development
of depression:
A. Genetic Factors:
• Family History: Depression can run in families, indicating a genetic predisposition. Individuals with a
family history of depression are at higher risk of developing the condition.

B. Biological Factors:
• Neurotransmitter Imbalances: Chemical imbalances in the brain, particularly involving
neurotransmitters such as serotonin, norepinephrine, and dopamine, are believed to play a key role in
depression.
• Hormonal Changes: Hormonal imbalances or fluctuations, such as those occurring during pregnancy,
postpartum, menopause, or due to thyroid disorders, can contribute to depression.
• Brain Structure and Function: Differences in brain structure, function, and connectivity, particularly in
regions like the hippocampus, amygdala, and prefrontal cortex, have been linked to depression.

2. What are the causes of depression? Contd.

C. Environmental Factors:
• Stressful Life Events: Major life changes, trauma, loss of a loved one, financial problems, relationship
difficulties, and other significant stressors can trigger depression.
• Childhood Adversity: Early life stress, abuse, neglect, or other adverse childhood experiences can
increase the risk of developing depression later in life.
D. Psychological Factors:
• Personality Traits: Certain personality traits, such as low self-esteem, pessimism, and a tendency to be
overly self-critical, can make individuals more vulnerable to depression.
• Cognitive Patterns: Negative thought patterns, such as those involving rumination and catastrophizing,
can contribute to and perpetuate depressive symptoms.
E. Medical Conditions:
• Chronic Illnesses: Conditions such as chronic pain, diabetes, cardiovascular disease, and others can be
associated with an increased risk of depression.
• Medications: Some medications, particularly those for high blood pressure, hormonal treatments, and
certain types of steroids, can have side effects that contribute to depression.

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3. How to diagnose depression?

Diagnosing depression in the medical profession involves a comprehensive evaluation that includes
a variety of steps to ensure an accurate diagnosis. Here are the primary components of the
diagnostic process:

A. Clinical Interview:
• History Taking: The healthcare provider will take a detailed medical and psychological history. This
includes asking about the onset, duration, and severity of symptoms, as well as any previous episodes
of depression or other mental health conditions.
• Current Symptoms: Detailed questions about the specific symptoms the patient is experiencing, such as
mood, sleep patterns, appetite, energy levels, concentration, and any thoughts of self-harm or suicide.
B. Physical Examination:
• A physical exam may be conducted to rule out other medical conditions that could be causing
depressive symptoms (such as thyroid disorders or vitamin deficiencies).

3. How to diagnose depression? Contd.

C. Diagnostic Criteria:

DSM-5 Criteria: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), provides
criteria for diagnosing major depressive disorder. A diagnosis typically requires at least five of the following
symptoms to be present for at least two weeks, with at least one symptom being either depressed mood or
loss of interest or pleasure:

• Depressed mood most of the day, nearly every day.

• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
• Significant weight loss when not dieting, weight gain, or decrease/increase in appetite.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt.
• Diminished ability to think or concentrate, or indecisiveness, nearly every day.
• Recurrent thoughts of death, suicidal ideation without a specific plan, or a suicide attempt.

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3. How to diagnose depression? Contd.

D. Screening Tools:
• Questionnaires and Scales: Tools such as the Patient Health Questionnaire-9 (PHQ-9), Beck Depression
Inventory (BDI), and Hamilton Depression Rating Scale (HDRS) are commonly used to assess the severity
of depression.
E. Laboratory Tests:
• Blood tests might be ordered to rule out other conditions that can mimic depression (e.g.,
hypothyroidism, anemia).
F. Psychiatric Evaluation:
• If necessary, the primary care provider may refer the patient to a psychiatrist or psychologist for a more
detailed evaluation and to confirm the diagnosis.
G. Assessment of Comorbid Conditions:
• Evaluating for other mental health disorders that might coexist with depression, such as anxiety
disorders substance use disorders, or bipolar disorder.

3. How to diagnose depression? Contd.

H. Functional Assessment:
• Assessing how symptoms are affecting the patient's ability to function in daily life, including work, social
relationships, and family life.

I. Risk Assessment:
• Evaluating the risk of suicide or self-harm and developing a safety plan if needed.

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4. Treatment of Depression
Current treatments for depression include a variety of approaches that can be used individually or
in combination, depending on the severity of the depression and the individual’s needs. Here are
the primary treatments:
A. Psychotherapy:

• Cognitive Behavioural Therapy (CBT): Focuses on identifying and changing negative thought patterns
and behaviours.
• Interpersonal Therapy (IPT): Addresses problems in personal relationships and social functioning.
• Dialectical Behaviour Therapy (DBT): Combines CBT with mindfulness techniques, often used for
people with severe depression or those who have suicidal tendencies.
• Psychodynamic Therapy: Explores unconscious patterns and emotional conflicts stemming from past
experiences.
• Behavioural Activation: Encourages engagement in activities that are aligned with personal values and
goals to combat inactivity and withdrawal.

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4. Treatment of Depression Contd.

B. Medications:
• Selective Serotonin Reuptake Inhibitors (SSRIs): Commonly prescribed antidepressants (e.g.,
fluoxetine, sertraline, citalopram).
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Increase levels of serotonin and
norepinephrine (e.g., venlafaxine, duloxetine).
• Tricyclic Antidepressants (TCAs): An older class of antidepressants (e.g., amitriptyline, nortriptyline).
• Monoamine Oxidase Inhibitors (MAOIs): An older class with dietary restrictions (e.g., phenelzine,
tranylcypromine).
• Atypical Antidepressants: Includes medications like bupropion and mirtazapine, which work differently
from other antidepressants.

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4. Treatment of Depression Contd.

C. Lifestyle and Self-Care:
• Exercise: Regular physical activity can improve mood and overall mental health.
• Healthy Diet: A balanced diet can have a positive impact on mood and energy levels.
• Sleep Hygiene: Maintaining a regular sleep schedule and good sleep habits.
• Mindfulness and Meditation: Techniques to manage stress and enhance emotional well-being.

D. Alternative and Complementary Therapies:

• St. John’s Wort: A herbal supplement that some people find helpful for mild depression (consult with a
doctor before use).
• Omega-3 Fatty Acids: Found in fish oil, may have mood-stabilizing effects.

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4. Treatment of Depression Contd.

E. Brain Stimulation Therapies:
• Electroconvulsive Therapy (ECT): Effective for severe depression unresponsive to other treatments.
• Repetitive Transcranial Magnetic Stimulation (rTMS): Uses magnetic fields to stimulate nerve cells in
the brain.
•Vagus Nerve Stimulation (VNS): Involves implanting a device that stimulates the vagus nerve.

F. Medication for Severe Cases:

• Esketamine (Spravato): A nasal spray for treatment-resistant depression, used under medical
supervision.
• Brexanolone (Zulresso): For postpartum depression, administered as an intravenous infusion.

G. Hospitalization or Residential Treatment:

• For individuals with severe depression who are at risk of harming themselves or are unable to care for
themselves.

Note: It’s important to note that treatment for depression is often most effective when it is personalised.

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Part Two:
Yu Zheng - 郁证 in TCM

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The Concept of Yu Zheng (郁证) in TCM

Yu Zheng (郁证) is a key concept in Traditional Chinese Medicine (TCM), often translated as "Depression
Syndrome" or "Constraint Syndrome." It reflects a pathological condition characterised by emotional
and physical disturbances resulting from internal constraint and stagnation.

The term "Yu" (郁) denotes stagnation, constraint, or depression, while "Zheng" (证) signifies a syndrome
or clinical pattern. Thus, Yu Zheng literally refers to a syndrome of stagnation or constraint.

In a broad sense, Yu encompasses stagnation or depression arising from external pathologic factors and
abnormal emotions , etc..

In a narrower sense, Yu specifically refers to stagnation or constraint caused by abnormal emotions ,

corresponding to disorders akin to depression and anxiety in Western medicine.

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Yu Zheng (郁证)

Neijing: Zhu Danxi of Yuan Dynasty:

Six Yu ( 郁 Stagnation)
Five Yu ( wood, fire, earth, metal, water);
1. Qi
2. Blood
3. Phlegm
4. Dampness
5. Fire
6. Food

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The TCM aetiology and pathology

of Yu Zheng will be discussed in class !

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Liver-Qi Stagnation
Main Manifestation
Depression, distension in the chest and hypochondrium, or fullness sensation in the stomach, often
belching, sigh, or irregular menses, thin and white tongue coating and taut pulse.

Acupuncture Prescription
Qimen (LR 14), Taichong (LR 3), Yanglingquan (GB 34), Zhigou (SJ 6), Neiguan (PC 6), Zhusanli (ST 36)

Supplementary Points
For irregular menses: + Sanyinjiao (SP 6) and Ligou (LR 5)

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Qi Stagnation Transforming into Fire

Main Manifestations
Hot temper, irritability, oppressed sensation in the chest, distension in hyphochodrium,
headache, red eyes, bitter taste in the month, stomach discomfort with acid regurgitation,
dark urine, constipation, red tongue with yellow coating, taut and rapid pulse.

Acupuncture Prescription
Qimen (LR 14), Xingjian (LR 2), Yanglingquan (GB 34), Neiting (ST 44), Zhigou (SJ 6))

Supplementary Points
For vomiting bitter fluids: + Riyue (GB 24)
For nausea, bitter taste in the month: + Zhongwan (RN 12), Jiexi (ST 41)

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Qi and Phlegm Stagnation(痰气郁结 - 梅核气)

Main Manifestations:
Feeling of a lump choking in the throat, unable to spit it out or to swallow it, chocking feeling
in the chest, with or without hypochondriac pain, white and greasy tongue coating, wiry-
slippery pulse.

Acupuncture Prescription:
Tiantu (Ren 22), Tanzhong (Ren 17), Neiguan (Pc 6), Fenglong ( ST 40), Taichong (LR 3)

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Heart Shen Malnourishment (心神失养)

脏躁 (Visceral Agitation)
Main Manifestations
Vague mind, restlessness, grief, worry easy to cry , poor sleep and feel sleepy. Pale tongue with
thin and white coating, wiry-thready pulse

Acupuncture Prescription
Shenmen (HT 7), Tongli (HT 5), Zhusanli (ST 36), Neiguan (PC 6), Sanyinjiao (Sp 6), Tanzhong (RN 17),
Xinshu (BL 15)

Supplementary Points
Fright and fear easily: + Danshu (BL 19), Ganshu (BL 18)

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Deficiency of Heart and Spleen

Main Manifestations
Over thinking, over worry, palpitation, timid, insomnia, poor memory, pale-yellowish face, dizziness,
low spirit, tiredness, poor appetite, pale tongue with thin-white coating, thready-weak pulse.

Acupuncture Prescription
Shenmen (HT 7), Xinshu (BL 15 ), Pishu (BL 20), Sanyinjiao (SP 6), Zhusanli (ST 36),
Zhongwan (RN 12), Zhangmen (LR13)

Supplementary Points
Severe depressed: + Neiguan (PC 6) and Taichong ( LR 3)

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Yin Deficiency of Liver and Kidney

Main Manifestations
Dizziness, palpitation, sleeplessness, restlessness, irritability, anger, 5 palm hot sensation, night
sweating, lower back pain and semi-emission in male, irregular menstruation in female, red tongue,
thready-rapid pulse

Acupuncture Prescription
Sanyinjiao(SP 6), Taixi (KI 3), Taichong (LR 3), Shenmen (HT 7), Xinshu (BL 15), Shenshu (BL 23),
Ganshu (BL 18)

Supplementary Points
Hot temper, irritability: + Sishencong, Yanlingquan (GB 34)

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Postpartum
Depression

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Three symptoms after birth

Jin Gui Yao Lue (Prescriptions from the Golden Chamber, Han dynasty):

▪ Convulsion
▪ Stagnation/Depression
▪ Difficult bowel movement

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Aetiology & pathology of postpartum

conditions in TCM
▪ Blood, body fluids and Qi insufficient
▪ Blood stasis
▪ External pathogenic factors attack
▪ Improper diet
▪ Emotional stress led to Qi stagnation

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Causes of Postpartum Depression

▪ depression during the pregnancy,

▪ worry and anxiety about the responsibility of having a new baby,

▪ a difficult delivery,

▪ lack of support at home,

▪ relationship worries,

▪ money problems,

▪ having no close family or friends around you,

▪ mental health problems in the past, such as depression or previous postnatal depression,

▪ physical health problems following the birth, such as anaemia or urinary incontinence.

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Symptoms of postpartum depression

• low mood for prolonged periods of time (a week or more),
• feeling irritable for a lot of the time,
• tearfulness,
• panic attacks or feeling trapped in your life,
• difficulty concentrating,
• lack of motivation,
• lack of interest in yourself and your new baby,
• feeling lonely,
• feeling guilty, rejected, or inadequate,
• feeling overwhelmed,
• feeling unable to cope,
• difficulty sleeping, and
• physical signs of tension, such as headaches, stomach pains, or blurred vision.

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Acupuncture Treatment of Postpartum Depression

Treatment principles Key acupoints

▪ Promote free flow of Qi, resolve blood

stagnation/stasis ▪ Yintang (EX)
▪ Strengthen the Spleen and Stomach ▪ Zhongwan (Ren 12)
▪ Guanyuan (Ren 4)
▪ Xuehai (SP 10)
▪ Zusanli (ST 36)
▪ Sanyinjiao (SP 6)
▪ Taichong (LR 3)

Note: Acupoints should be tailored to each individual case.

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