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Strangely enough, the condition of post-natal depression is not mentioned in modern Chinese books and the discussion of it in this chapter draws primarily on old gynaecology and obstetrics books. Post-natal depression is usually explained in Chinese medicine in terms of Blood: the exertion and loss of blood occurring at childbirth induce a state of Blood deficiency; since the Heart houses the Mind and governs Blood, Heart-Blood becomes deficiency, the Mind has no residence and it becomes depressed and anxious. This causes a state of depression, mild anxiety, insomnia and fatigue: on a mental level the mother feels unable to cope, she is tearful, she loses any libido, and she may feel angry or guilty. From Blood deficiency, other conditions may develop: after some time, and in women who have a predisposition to Yin deficiency, Blood deficiency may give rise to Yin deficiency and Empty Heat. This would cause a more severe condition of depression with more intense anxiety, insomnia, mental restlessness and agitation. Conditions of neurotic, obsessive, phobic or psychotic behaviour after childbirth are usually due to stagnant Blood harassing the Mind (rather than the more common Phlegm-Heat). In such cases, the woman is not only depressed but also confused, she may display obsessive behaviour or phobias and, in extreme cases, she may manifest psychotic or even schizophrenic behaviour. She may be aggressive and offensive, she may have hallucinations and delusions and she may display suicidal tendencies and even harbour destructive thoughts against her baby. In old China, there were various conditions describing the above situations. Chan Hou Wang Yan Wang Jian means "absurd speaking and absurd seeing after childbirth": this indicates a delusional state with incoherent speech and hallucinations. Chan Hou Wang Yan Jian Gui Fa Kuang means "absurd speaking, seeing ghosts and manic behaviour after childbirth" and it indicates incoherent speech, visual and acoustic hallucination and hypomania. It was described by Wu Qian in his "Golden Mirror of Medicine" (1742). Chan Hou Xu Fan means "mental restlessness after childbirth" and it indicates a state of mental restlessness, insomnia, and a feeling of heat in the evening, normally associated with Yin deficiency. Chan Hou Jing Ji means "palpitations and anxiety after childbirth" and it indicates palpitations, anxiety, and a flustered and confused state after childbirth, normally associated with Blood deficiency. Chan Hou San Chong means "three rebellions after childbirth" and it indicates three conditions all resulting from retention of lochia and stasis of Blood in the Penetrating Vessel, affecting the Heart (causing mental confusion, manic behaviour or depression, a feeling of oppression of the chest, mental restlessness and hysteria), the Lungs (breathlessness, cough, feeling of oppression of the chest) or the Stomach (a feeling of oppression of the epigastrium, nausea, vomiting, abdominal pain and fullness). AETIOLOGY AND PATHOLOGY 1) EXCESSIVE LOSS OF BLOOD DURING CHILDBIRTH Excessive loss of blood during childbirth causes Blood deficiency; since the Heart houses the Mind and governs Blood, deficient Heart-Blood fails to house the Mind which becomes depressed and anxious. In women with a pre-existing deficiency of Blood, this situation may arise even if the blood loss during childbirth is not particularly heavy. Deficiency of Blood will cause depression, resulting in a case of Mind Weakened; if the deficiency of Blood gives rise also to anxiety and insomnia, it may result in Mind Weakened and Unsettled. 2) BLOOD STASIS AFTER CHILDBIRTH Blood stasis after childbirth occur frequently, especially in women who have a pre-existing state of stasis of Blood. Stagnant Blood rebels upwards in the Penetrating Vessel and harasses the Heart (though which the Penetrating Vessel flows): as the Heart governs Blood and houses the Mind, stagnant Blood harasses and obstructs the Mind. This is a case of Mind Unsettled and Obstructed. 3) CONSTITUTIONAL TENDENCY TO MENTAL-EMOTIONAL PROBLEMS A constitutional tendency to mental-emotional problems is often the basis for the development of mental problems after childbirth. The signs that may indicate such a tendency are:
Figures 1 and 2 illustrate the first and second types of tongue, i.e. one with a deep Heart crack and one that is hammer-shaped. Thus, the pathology of Post-natal Depression is centred around Blood: it is due either to a Blood deficiency, or to a Blood deficiency turning into Yin deficiency, or to Blood stasis. The principal organ involved is always the Heart: Heart-Blood deficiency, Heart-Yin deficiency or Heart-Blood stasis respectively. However, other organs are involved too: a state of Heart-Blood deficiency after childbirth nearly always involves Liver-Blood deficiency; a state of Heart-Yin deficiency is frequently associated with Liver- and/or Kidney-Yin deficiency; and a state of Heart-Blood stasis is nearly always associated with Liver-Blood stasis within the Penetrating Vessel. The main treatment principles adopted in post-natal depression from deficiency of Blood or Yin are therefore to nourish Blood or Yin and calm the Mind, and, in post-natal psychosis, to calm the Mind, invigorate Blood, eliminate stasis and open the Mind’s orifices. Psychotic, manic or schizophrenic behaviours are all manifestations of obstruction of the Mind and one must therefore open the Mind’s orifices with herbs such as Shi Chang Pu Rhizoma Acori graminei, Hu Po Succinum, Yu Jin Tuber Curcumae, He Huan Pi Cortex Albizziae julibrissin, and Yuan Zhi Radix Polygalae tenuifoliae. Acupuncture points that open the Mind's orifices include: P-5 Jianshi, Du-20 Baihui, Du-26 Renzhong, ST-40 Fenglong, ST-25 Tianshu, all the Well points, G.B.-17 Zhengying, G.B.-18 Chengling, Du-19 Houding, G.B.-13 Benshen, SP-1 Yinbai and Du-18 Qiangjian. DIFFERENTIATION AND TREATMENT The patterns discussed are three:
1) HEART-BLOOD DEFICIENCY Clinical manifestations Post-natal depression, fatigue, mild anxiety, insomnia, tearfulness, a feeling of guilt, loss of libido, poor memory, palpitations. Tongue: Pale and Thin. Pulse: Choppy and Weak on the left side, especially on the Middle and Front positions. Treatment principle Nourish Blood, strengthen the Heart, lift mood. Acupuncture HE-5 Tongli, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, BL-15 Xinshu, LIV-8 Ququan, Du-20 Baihui, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-19 Houding, P-6 Neiguan. All with reinforcing method, except Du-19 which should be needled with even method. Moxa is applicable. Herbal treatment a) Prescription FU SHEN SAN Poria Powder Ren Shen Radix Ginseng 6g Explanation Wu Qian in his "Golden Mirror of Medicine" (1742) recommends this formula for palpitations, anxiety and confused behaviour after childbirth. The term I have translated as "confused behaviour" is huang hu which means "absent-minded" or "as if in a trance". b) Prescription GUI PI TANG Variation Tonifying the Spleen Decoction Ren Shen Radix Ginseng 6g (or Dang Shen Radix Codonopsis pilosulae 12g) Explanation The formula Gui Pi Tang, already explained, tonifies Spleen-Qi and Heart-Blood and calms the Mind: it is ideally suited to treat post-natal depression and insomnia. This formula is also recommended by Wu Qian in his "Golden Mirror of Medicine" for post-natal depression from worry, pensiveness and sadness. Long Chi has been added to calm the Mind. Three Treasures remedy CALM THE SPIRIT Ren Shen Radix Ginseng Explanation This remedy is a variation of the formula Gui Pi Tang Tonifying the Spleen Decoction which tonifies Heart- and Spleen-Qi and Heart- and Spleen-Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Case history A 35-year-old woman had been suffering from depression and insomnia since the birth of her first child 2 years previously. She felt very depressed, had negative thoughts and found everything an effort. In addition, she slept badly, with nightmares, and woke up frequently during the night; she also experienced a floating sensation just as she was about to fall asleep. On interrogation, it transpired that she also suffered from poor memory, tingling of the limbs, palpitations, a feeling of heat at night, night-sweating, dry eyes, and a dry mouth and throat at night. Her periods were regular but rather scanty, lasting only 3 days. Her tongue was Thin, with a shallow Heart crack, and had generally a normal colour except for being Red on the tip. Her pulse was Fine. Diagnosis This is a clear case of Liver- and Heart-Blood and Liver-Yin deficiency. The symptoms of Liver-Blood deficiency are: depression, insomnia, tingling of limbs, poor memory, scanty periods, Thin tongue and Fine pulse. The symptoms of Liver-Yin deficiency are: feeling of heat at night, night-sweating, dry mouth and throat at night, a floating feeling just before falling asleep, nightmares and dry eyes. Although the tongue does not show any Yin deficiency, this simply means that the Yin deficiency is of recent date and not yet severe enough to show on the tongue. The deficient Liver-Blood and Liver-Yin fail to root the Ethereal Soul at night, hence the insomnia and nightmares; the floating sensation just before falling asleep indicates Liver-Yin deficiency. The wandering of the Ethereal Soul which results from the deficiency of Liver-Blood and Liver-Yin also induces a state of aimlessness, depression and despair. Apart from the patterns of Liver-Blood and Liver-Yin deficiency, there is also some Heart-Blood deficiency evidenced by the palpitations. The tip of the tongue is Red from some Empty Heat arising from the Yin deficiency and affecting the Heart. The midline Heart crack indicates a constitutional tendency to Heart patterns and emotional problems. However, this Heart pathology is secondary to that of the Liver. Treatment principle The treatment principle adopted was to nourish Liver-Blood and Liver-Yin, nourish Heart-Blood, calm the Mind and settle the Ethereal Soul. This patient was treated with both acupuncture and herbs. Acupuncture The main points used were selected from the following: Ren-4 Guanyuan to nourish Blood and Yin. Ren-15 Jiuwei to calm the Mind. ST-36 Zusanli, SP-6 Sanyinjiao and LIV-8 Ququan to nourish Liver-Blood. Herbal treatment The herbal formula used was a variation of Yi Guan Jian One Linking Decoction which nourishes Liver-Yin: Dang Gui Radix Angelicae sinensis 6g Explanation Dang Gui, Bai Shao, Shu Di Huang, Shou Wu and Gou Qi Zi nourish Liver-Blood. Bai Shao is astringent and roots the Ethereal Soul in the Liver. Gou Qi Zi also nourishes Liver-Yin. Mai Men Dong, Shan Zhu Yu and Wu Wei Zi nourish Yin. Wu Wei Zi and Shan Zhu Yu are also astringent and therefore help to root the Ethereal Soul in the Liver. Wu Wei Zi also calms the Mind. Long Yang Rou, Ye Jiao Teng and Bai Zi Ren nourish Blood, calm the Mind, promote sleep and settle the Ethereal Soul. Han Lian Cao clears Empty Heat arising from Liver-Yin deficiency. Chuan Lian Zi moves Liver-Qi and counterbalances the cloying effect of the Blood and Yin tonics: it is also one of the few herbs that move Liver-Qi without injuring Yin. After 6 months of treatment along the above lines, this patient’s mood returned to normal, her depression lifted and her sleep became much deeper. 2) HEART-YIN DEFICIENCY Clinical manifestations Post-natal depression, insomnia (waking up frequently during the night), mental restlessness, a feeling of guilt, exhaustion, scanty breast milk, palpitations, loss of libido, a feeling of heat in the evening, night-sweating. Tongue: Red without coating, with a Heart crack. Pulse: Floating-Empty. Treatment principle Nourish Yin, tonify the Heart, calm the Mind. Acupuncture HE-7 Shenmen, HE-5 Tongli, P-7 Daling, Ren-14 Juque, Ren-15 Jiuwei, Du-19 Houding, Du-24 Shenting, Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao. All with reinforcing method, except for the point on the head which should be needled with even method. No moxa. Herbal treatment a) Prescription REN SHEN DANG GUI TANG Ginseng-Angelica Decoction Ren Shen Radix Ginseng 6g Explanation This formula is also recommended by Wu Qian in his "Golden Mirror of Medicine". b) Prescription TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill Sheng Di Huang Radix Rehmanniae glutinosae 12g Explanation This formula, already explained, is used if, in addition to Heart-Yin deficiency, there is also Kidney-Yin deficiency. It nourishes Blood and Heart- and Kidney-Yin, calms the Mind and clears Empty Heat. c) Prescription AN XIN TANG Calming the Heart Decoction Dang Gui Radix Angelicae sinensis 60g Explanation This formula from "Fu Qing Zhu's Gynaecology" is for depression and psychotic behaviours after childbirth caused by Blood deficiency with Empty Heat harassing the Heart. Women's Treasure remedy HEAVENLY EMPRESS Sheng Di Huang Radix Rehmanniae glutinosae Explanation This remedy is a variation of the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill which nourishes Heart- and Kidney-Yin, clears Heart Empty Heat and calms the Mind. 3) HEART-BLOOD STASIS Clinical manifestations Post-natal depression, manic behaviour, scolding people, aggressive behaviour, delusions, hallucinations, suicidal, destructive thoughts, lack of bonding with the baby. Tongue: Purple. Pulse: Wiry, Rapid. Treatment principle Invigorate Blood, eliminate stasis, subdue rebellious Qi in the Penetrating Vessel, calm the Mind, open the Mind’s orifices. Acupuncture P-7 Daling, G.B.-17 Zhengying, G.B.-18 Chengling, Du-24 Shenting, Ren-14 Juque, BL-15 Xinshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-1 Yongquan, LIV-3 Taichong, BL-17 Geshu, SP-10 Xuehai. All with reducing method. Herbal treatment a) Prescription XIAO TIAO JING TANG Small Regulating the Menses Decoction Bai Shao Radix Paeoniae lactiflorae 3g Explanation This formula from the "Golden Mirror of Medicine" is for Blood which is both deficient and rebelling upwards to harass the Heart causing post-natal psychosis. b) Prescription SHA XIANG SAN Cinnabaris-Musk Powder Ren Shen Radix Ginseng 6g Explanation This formula is also from the "Golden Mirror of Medicine" and is specific for post-natal psychosis. What we now call psychosis was described as "seeing ghosts and incoherent speech" in the original text. The use of Zhu Sha is now illegal and we should therefore replace it with Long Chi Dens Draconis 12g. Three Treasures remedy RED STIRRING Dang Gui Radix Angelicae sinensis Explanation This remedy is a variation of the formula Xue Fu Zhu Yu Tang Blood-Mansion Eliminating Stasis Decoction which invigorates Blood and eliminates stasis in the Upper Burner. The remedy has been modified from the original formula with the addition of herbs that calm the Mind and open the Mind’s orifices. The tongue presentation appropriate to this remedy is a Purple body. PROGNOSIS AND PREVENTION Post-natal depression responds very well to treatment with acupuncture and Chinese herbs and the overwhelming majority of cases can be helped in a relatively short period of time, perhaps a few months. The pattern from Blood deficiency is easier to treat than that from Yin deficiency. Post-natal psychosis is much more difficult to treat and, in severe cases, Chinese treatment may have to be combined with Western medication, especially if the mother is suicidal or destructive towards the baby. In any case, the signs that point to a poor prognosis are:
REPLY TO COMMENTS The chapter on post-natal depression in my book "Obstetrics and Gynaecology in Chinese Medicine", from which this article is taken, has been commented upon by some authors. In reply, I would like to say first of all that, as this subject is not discussed in modern Chinese books, I have followed only classical texts and primarily Wu Qian’s "Golden Mirror of Medicine" (Yi Zong Jin Jian, 1742). The patterns that I present are those I found in this text: I did not find other patterns discussed in the context of post-natal depression. Of course, it may well be that the chapter on post-natal depression suffers from omissions especially since it is the first to appear in English on this subject. One comment was that the patterns presented are not enough and that there are other patterns which cause depression. I think these comments are based on a basic misunderstanding and confusion between depression in general and post-natal depression. Post-natal depression is, by definition, depression starting soon after childbirth in a previously mentally-healthy woman: if the woman was already suffering from depression before pregnancy and childbirth, then it is not post-natal depression. The pathology of post-natal problems is strongly dominated by a Blood pathology as it is in many other post-natal problems, e.g. joint pains after childbirth, post-natal abdominal pain, etc. Thus, it is not surprising that the Golden Mirror of Medicine discusses the above Blood patterns in post-natal depression. Some authors have commented on Phlegm as a pattern in post-natal depression: this cannot be for the reason mentioned above. Post-natal depression develops fairly soon after childbirth in a previously mentally-healthy woman: Phlegm is a complex pathogenic factor that is the result of a long-standing disharmony and takes a long time to form. Thus, it cannot be a pattern causing post-natal depression because it cannot be formed so quickly after childbirth. Other authors mention Liver-Qi stagnation as a pattern in post-natal depression because the mother is subject to so much stress soon after childbirth. This is a basic misunderstanding of the diagnosis of patterns: a pattern is diagnosed not from the aetiology but from the clinical manifestations. In other words, we can diagnose that a patient suffers from Liver-Qi stagnation if he or she presents with the symptoms and signs of Qi stagnation, not on the basis of an observation of the patient’s life events. The fact that the mother is subject to considerable stress after childbirth does not necessarily imply that she suffers from Liver-Qi stagnation: the same stress may cause many other patterns, e.g. Heart-Blood deficiency, Heart-Blood stasis, etc. Of course, that is not to say that in practice the patterns appearing in post-natal depression are simply those indicated in the above article as every woman will have pre-existing disharmonies which will change the clinical picture: but this applies to any disease, not just post-natal depression. Thus, it may well be that a woman suffering from post-natal depression may suffer from Phlegm or Qi stagnation in addition to the Blood patterns discussed above, but these will be pre-existing patterns. Some authors assert that there cannot be mental depression without Liver-Qi stagnation: this is patently absurd as many other (including purely Deficient) patterns (e.g. Heart-Blood deficiency, Kidney-Yang deficiency) may cause mental depression as one can verify in any modern or ancient Chinese medicine book. Perhaps this misunderstanding arises from the Chinese word yu which is used both to indicate depression and Qi stagnation: another good reason for translating it as "stagnation" (rather than depression) when it is in the context of Liver patterns. Copyright (c) Giovanni Maciocia 2000
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