Diagnosis and Treatment of Depression in Chinese Medicine and Acupuncture - Part 1

Depression: Loss of Movement, Decline in Spirit

Depression is characterized by a marked decline in mood, willpower, drive, and sense of vitality. The patient reports difficulty being in motion, doing, presence, and enjoyment - experiencing an existential sense of heaviness and an extinguished state of lifeless ash that persists over weeks and sometimes months.

In the classics of Chinese medicine, there is an almost automatic recourse to the Wood element - the Liver (LIV) - due to the many common symptoms of Qi stagnation. Moving Qi is undoubtedly a central component of treatment, but without diagnosing the underlying reasons, it is akin to trying to start a car without a battery. There is no movement without a source. In most cases, depression is indeed a blockage, but not merely a blockage: it is also a deficiency - of Yin, of Blood, of Qi, of hope. Therefore, one must diagnose: where did the connection unravel?

In states of deep depression, all Five Elements are involved to varying degrees - H/E/M. Therefore, for every patient, a treatment strategy must be constructed to first determine the starting point from which the problem originated, and from there begin treatment. One should endeavor less to "chase symptoms." Once the main line is found, one must follow this strategy, because ultimately in many cases, symptoms converge.

One must distinguish between two main types: acute conditions originating from trauma - sudden loss, divorce, a crisis life event. Here we mostly see a direct hit to the Heart and the Shen, and sometimes also to the Spleen or Lung or both. Chronic conditions, a personality-based depressive tendency - these are more complex, not necessarily the result of an external event, but an ingrained pattern. This requires deeper, long-term treatment, as usually all Five Elements will be involved.

Between the two lies the phenomenon of melancholy, which does not stem from a personality disorder yet is very common. A feeling of emptiness, inner heaviness, procrastination, sadness without cause - these are expressions of melancholy, and most patients find it difficult to explain why they feel the way they do.

The Water Element - (KI/BL)

Kidney function (KI) in terms of Blood, Qi, Yin, Yang - the Water element can represent the initial stage of inward gathering, or the deepest stage: the one in which willpower is lost.

A sharp weakening or collapse of the Water element causes the patient to want to disappear into their inner world, into a diffuse, closed, and disconnected realm where emotional expression barely exists. At times, the experience of rupture stems from losing the direct connection between Kidneys and Heart - between Water and Fire, a state of imbalance between Yin and Yang in the Kidneys, manifesting in a loss of communication and an apathetic withdrawal into a gloomy, hopeless, and extinguished world.

In most cases of depression we will also observe Liver Qi stagnation, but often this is a secondary symptom: a deficiency in Kidney Yang causes an inability to warm and support Qi movement in the Liver, resulting in stagnation and a feeling of "zero movement." The patient complains of cold, extremely low energy levels, diminished and delayed psychomotor behavior, slow speech, and heavy body movements. This is a period of total withdrawal, of deep self-neglect, and at times suicidal impulses emerge - for just as water always strives toward the source, so too a person sinks here into the primordial inner content, to the place preceding any realization, an attempt to return to the starting point and find the mental strength to "start anew," propel a vision, or find goals for which it is worth striving and renewing strength.

The spiritual aspect of the Kidneys is the Zhi - willpower. It is connected to Jing and is part of the Shen; it represents potential yet is nourished by consciousness, acquired experiences, and memory. The Zhi is the connection between potential and acquired experience, and it is what allows potential to become a tangible reality. This is precisely what a patient with depression cannot find within themselves, for there is no willingness to face the outside world, no identification of self-will - on the contrary, there is helplessness and dispersion, giving rise to symptoms of extreme fatigue, withdrawal, escaping confrontation, difficulty performing actions, aversion to human company, and a sense of impending doom.

Loneliness and Solitude - Two Distinct States

The second significant theme at the core of the depressive experience is loneliness. But it is important to distinguish between two different states: loneliness and solitude.

Loneliness is a state of disconnection - a feeling that you live in the world but receive no feedback for your thoughts, emotions, or statements. You feel irrelevant to the world, possessing nothing to contribute, as life moves at a pace that is not yours. Your boundaries - internal and external - are unclear to you. You drift into the open sea lying on your back, finding yourself in an experience of disconnection with no land in sight on the horizon.

Solitude is an entirely different state. A person experiences that same inner sinking, self-knowledge, and depth, but the process is directed and protected. Earth is stable, Metal nourishes Water, and one can be alone and feel safe. They know how to separate the trivial from the essential, guide themselves, and return to the world from a more whole place. This is the capacity to navigate life solely with what is found within and springs from within, carrying immense inner power.

The Water element, by its very nature, carries a diffuse quality: it distances itself when lacking focus - a mechanism aimed at protection, holding wisdom within. Yet in an unbalanced state, when distance becomes permanent, it is no longer merely disconnection but sinking. Here begins the experience of aimlessness, because willpower is unclear, connection to others vanishes, and the distance from the self steadily grows, as the entire concept of the Water element regarding "self-knowledge" drowns in deep waters and scatters.

Here enters the importance of the relationship between the Earth element and Water: Earth balances, grounds, and holds Water within boundaries. In a healthy state, a person can be "measuredly detached" - present and sensitive, yet preserving privacy, present without being overly entangled. In a state of depression, when Earth is too weak to balance Water, Water rises, self-identity blurs, and the system sinks into itself, losing boundaries and connection to the world's stability.

The support of the Metal element to the Water element is also significant: the Metal element grants Water focus, definition, values, and logic. A lack of support from Metal adds symptoms of a sense of sin, guilt, and self-criticism. Metal helps Water define appropriate values, laws, and boundaries, allowing for organization and order that are vital for the proper function of the Water element.

The Wood Element - (LIV/GB)

The Liver (LIV) is responsible for the movement of Qi and its free flow, and in every state of depression we observe symptoms of Liver Qi stagnation. This is perhaps one of the most common phenomena, yet not necessarily the source, as Liver stagnation is often the result of deficiency elsewhere.

One common cause is Blood deficiency, stemming in part from nutritional neglect: loss of appetite, weight loss, impaired function of organs such as Kidneys, Lungs, Spleen, or Heart. When Blood is lacking, the Liver is not properly nourished and Qi becomes blocked and depleted. Another reason is Phlegm, which blocks pathways and weakens Spleen functions of transformation and transportation. Qi stagnation and Phlegm cause overheating in the Liver - Damp-Heat moving to the Heart and harming the Shen.

The symptoms created by Qi stagnation are those troubling the patient most in daily life: heaviness, lack of movement, slowness, extreme weakness. Often one hears: "If only my energy would return, everything would be fine." But this fails to address the depth of the problem. Willpower is extinguished, the mind retreats, and fatigue is not merely physical but mental. We too, as practitioners, can fall into this trap - wanting to "move," to "circulate," without seeing the complete picture. A depressed patient frequently lives in denial regarding their true state, viewing it as temporary while inwardly fearing it is permanent. Thus, they grow angry at those around them asking to "snap out of depression," sometimes seeking to move the system here and now without building Qi and Blood, transforming moisture, or understanding the reasons for their condition and the source of the problem, making Qi movement alone an unsustainable solution.

The Wood element is entrusted with "bringing into execution" - what is brought into execution? The very willpower defined in its mother element, the Water element. Yet if no willpower exists, how can action occur? Precisely here, one frequently sees an effort to "do something" in an attempt to move the system, but because the action rests not on genuine, stable desire but on "fear that unless I act no change will happen," there is an "attempt to start" that scatters as quickly as it arrives. Thus, situations arise where all actions are postponed to the future, tomorrow, a little later - yet lacking resources, there is no action, no drive, and nothing brought to light, exacerbating the cycle of suppression.

Qi stagnation causes a constant sense of distress - an expression and attempt to move, accelerate, and find a quick solution precisely for a condition requiring calm and relaxation. Distress produces anger, and the root of anger lies deep within the Water element, in fear - in what is unsettled, in knowing there is insufficient information about what is happening, which impairs functioning as the general feeling is one of lacking control, heightening fear. There is hesitation, inability to make decisions, reduced initiative and movement, and avoidance of anything that might expose the person to situations of lacking control.

Sleep problems are highly characteristic of depressive states - a tendency toward excessive sleep, yet with early morning awakening where emotional symptoms and delusions tend to worsen, easing toward evening. There are states with difficulty falling asleep, awakenings, and hard morning arousal - primarily due to Blood deficiency affecting the mental aspect of the Liver, the Hun. The Hun, the ethereal soul, carries a Yang quality yet relies on Yin and Blood to function. When ungrounded, sleep quality degrades, the capacity to dream willpower, imagine, hope, and experience inspiration is impaired. It loses connection with the universal subconscious, and the person experiences floating, confusion, detachment, as if not truly connected or present in the world. This is a state of directionless void - frequently leading to worsening depression.

The Fire Element - (HT, PC, SI, TH - Shen)

In every prolonged depressive state, impairment of the Shen, Heart (HT), and Pericardium (PC) will appear. Everything described thus far - Kidney Yin or Yang deficiency, Blood deficiency, Liver Qi stagnation, Spleen Phlegm, Heat and Phlegm-Heat in the Liver - all these can lead to a condition where the Shen is not present in a state of ease.

At certain stages, especially in depression with psychotic components, we see anxiety, hallucinations, delusions, and severe insomnia. Anxiety itself, unlike fear, stems from an unknown source - a sense of confusion between bodily stimuli and mental illusions, a state where a person repeatedly falls victim to their sensations. Heart (HT) Heat with or without Phlegm corresponds to accompanying symptoms of acute anxiety, and in psychotic depression, hallucinations, insomnia, and delusions manifest.

When there is Heart Blood deficiency (even without Heat), symptoms are no less severe: exhaustion, deep sadness, uncontrollable weeping, lack of desire for human connection, loss of sexual desire, and overall psychomotor retardation. A condition frequently appearing in mild depression, melancholic states, or in individuals with delicate emotional tendencies.

The Heart, at the core of all this, is responsible for the Shen - the spark of heavenly consciousness. It resides in the Heart, expresses through Blood, and affects the Heart. Information moves through the body via the Triple Burner (TH) and Pericardium (PC). When Blood is weak, Heart Yin is deficient, or the Shen is disturbed, senses of insight, memory, concentration, intuition, feeling, and inner listening become unsettled. The person feels disconnected: from self, environment, the capacity to understand oneself, or feel one's heart. This is that same feeling of "living in someone else's dream" reported by patients - where the world appears distant and distorted, as though everything happens "not for real."

The Pericardium (PC) and Triple Burner (TH)

The Pericardium (PC) protects the Heart - it regulates the entry of emotional information, filtering what arrives from the world, allowing the Heart to receive only what passed filtration. When the PC weakens, this protection breaks. The person becomes highly vulnerable, shaken by every sound, with every bit of emotional information, however minor, entering with extreme force and unsettling them.

The Triple Burner (TH) transmits data through Qi channels and fluids from the source (Yuan), creating coordination among bodily systems. But when the PC is weak, regulation falters. The Heart becomes overwhelmed; there is no filter. This manifests as delusions, hypersensitivity, exaggerated excitement, or alternatively, frozen apathy.

When the Shen does not function properly, clear communication between the Heart and the other mental aspects - Hun, Yi, Zhi, Po - ceases. Internal attention falters, logic clouds, awareness contracts, and life becomes an emotional blur. A person loses joy, pleasure, the small illumination within the Heart. If there is no flow between Heart, Pericardium, and TH, joy is absent, and the inner world becomes darker, heavier, too quiet.

The Earth Element - (SP/ST)

The initial feeling of a patient in a state of depression is the rug pulled from under their feet - a sensation that their world as they knew it has ended. A feeling takes hold where gripping reality or a familiar, stable anchor is impossible, worsened as loneliness grows and the thought arises that this condition will remain forever. In other words, Earth's stability becomes polar, signaling that uncertainty, insecurity, and instability are the permanent state. From here, the path to losing security, hope, and interest in life is short.

Physiologically, the Earth element is responsible for the process of transformation and transportation of food and fluids. When the Spleen weakens, Dampness forms, Phlegm is generated, and pathways become obstructed. This slows Qi movement, burdens the body, and directly impairs the quality of consciousness. Loss of appetite, weight loss or gain, general weakness - all derive from improper SP function, sometimes accompanied by binge eating or shifting eating patterns. As Phlegm obstruction increases, it generates Heat or Phlegm-Heat obstructing pathways and reaching the Liver and Heart, exacerbating the psychiatric-psychotic symptoms of depression.

Yi - Thought Processes

One of the most severely impacted aspects in depressive states is the Yi - the conscious aspect linked to the Spleen. This is the part responsible for thinking, learning, information processing, and short-term memory. When the Spleen weakens, the capacity to absorb impressions, comprehend occurrences, and process experiences logically is disrupted.

Thought becomes cyclical, obsessive, clinging to details. Every idea splits into dozens of possibilities, with no inner ground permitting sorting, filtering, and deciding. The result: an inner explosion of thought, an inability to discern what is correct and appropriate - and life is experienced like a maze with no way out. In such a state, every stimulus becomes a threat. The person weakens, loses interest, drawn into passivity turning to apathy. A sense of impending doom rises, along with delusions, and at times, thoughts of total loss because the ground has vanished.

The central difficulty lies in the ability to act. The person thinks, ponders, weighs, yet fails to formulate action. There is no decision, no direction, no initiative, for without Earth there is no movement translating the internal outward. Depression here is not merely an emotional state, but the result of losing the ability to sustain action rooted in internal harmony. And this is one of the deepest causes of classic depression.

The Metal Element - (LU/CO)

In terms of emotional affiliation, depression is a derivative of the Metal element emotion: melancholy. Melancholy is an endogenous depressive state, very common even among those not plunged into deep depression. The core feeling is fog - a person feels they live and function within an inner fog. In any case, a decline in operational capacity, pleasure, and desire occurs, and in aggravated states turns into depression with insomnia, fatigue, and extreme exhaustion.

When Spleen (SP) transformation and transportation processes are impaired, the Lung (LU) distribution function is also damaged, as quality Gu Qi does not reach the Lung from the Spleen. If the Lungs govern the distribution and flow of Qi, then a depressive state of Qi deficiency and stagnation clearly explains phenomena of heaviness, slowness, and dysfunction. Usually accompanied by profuse sweating, shortness of breath, weak voice, fatigue from speaking, and a decline in the Lung's control over Wei Qi inviting easier penetration of Wind and external pathogens.

The decline in Lung (LU) function reduces mental capacity in terms of separation, regulation, definition, sifting trivial from essential, focus, and precision. When this happens, a "cloudy" state appears - a feeling of mush in the head, cloudiness, heaviness, where logic fails to show up. The reduced ability to control oneself typically triggers obsession and a search for control. Repression takes place, and the patient feels resentment toward those around demanding they "get over it." Functional decline causes mental deterioration characterized by weeping, crying fits, and an inundation of inappropriate guilt feelings and self-hatred.

Po - The Corporeal Soul

The Po, the mental/spiritual aspect of the Lungs, is responsible for the person's connection to the body, feelings, and basic existential actions. When the Po is harmed, the sense of grounding is shaken. The person narrows their operational range, withdraws from the world, enclosing themselves in as narrow a space as possible to maintain control, failing to let go because they are in a survival state.

In a depressive state, the Po clings to what exists. Any attempt at change is experienced as a threat. Withdrawal, a sense of suffocation, fear of exposure, and inward retreat into sadness and shame ensue. The connection between mind and body is damaged, and a tendency toward loneliness, self-criticism, low self-worth, and sometimes self-hatred emerges. This severely damages the image a person has of themselves, their capabilities, and their ability to function in the world.

The Metal element is responsible for releasing and letting go. It is designed to allow us to breathe, release, and hold gently. Yet in depression, Metal contracts. It suffocates instead of softening. It narrows instead of expanding. Thus the connection to breath, movement, and the possibility of opening the heart is lost. Depression, then, is not a failure. It is a person's opportunity to observe oneself and at a certain point, begin building their system: the connections, the wiring, the balance among the elements. Our work in Chinese medicine is to rewire these connections, treat physiological organs, and find balance in movement - but without awareness of these matters, without diagnosis, and without understanding the person's process, helping them emerge from this state will be extremely difficult. What a person in a state of depression needs is hope: the hope that change can arrive and manifest.