Foreword by Heiko Lade: This article first appeared in the Newsletter of the Australian Chinese Medicine Education and Research Council, Ltd, August, 1997 Vol 3:1. It has been reprinted here with kind permission of Steve Clavey, the former Secretariat of the Newsletter. Steve Clavey is well known for his numerous articles on TCM that have been released in many journals and is a regular speaker at the Annual TCM Rothenburg Conference in Germany.
Over the years a number of people have contacted the editor looking for information on the Chinese treatment of post-natal depression. The question seems simple enough, straightforward; but simple questions do not always have simple answers.
The different structuring of syndromes between Western medicine and Chinese medicine causes the difficulty which one has in locating information about a number of conditions, such as irritable bowel syndrome, chronic fatigues syndrome, premenstrual syndrome and so on.
The Ji Yin Gang Mu (Compendium of Benefits to Women, 1620, by Wu Zhi-Wang) is a major TCM gynaecological text which contains gynaecological formulae arranged by disease category. It contains more than fifty formulas listed for these various conditions, as well as others that in the West might conceivably be thrown into the “post natal depression” basket, such as recurring hiccups or wandering pains.
The commentaries included within the Ji Yin Gang Mu note that there are three major approaches to post-partum emotional disorders.
These and other similar conditions share several characteristics: 1) they are usually conditions for which Western medicine is not very useful, and b) they tend to be a large grab-bag of symptoms.
Our topic here is one such broadly-defined category, because “post natal depression” is a Western term, and is not matched by an equivalent simple category in Chinese medicine. This is because in Chinese medicine the “syndrome” is broken down into its various clinical manifestations, including:
产后不语 chan hou bu yu Post Natal Aphonia (difficulty speaking)
产后惊悸 chan hou jing ji Post Natal Palpitations (including “panic attacks”)
妄言谵语 wang yan zhan yu Post Natal Hysteria (delirious speech)
乍见鬼神 zha jian gui shen Post Natal Hysteria (Hallucinations)
产后恍惚 chan hou huang hu Post Natal Attention Deficit (forgetfulness)
产后虚烦 chan hou xu fan Post Natal Deficient Flushing (hot flushes up the chest)
产后癫狂 chan hou dian kuang Post Natal Insanity (frank psychotic behaviour)
One focuses on “bad blood” (败血 / bai xue) left over after the birth, which rushes to and disrupts the Heart shen. Another emphasises blood deficiency resulting from the birth process and its attendant traumas.
The last points to pathogenic wind taking advantage of the blood deficiency to attack. Naturally these approaches offer radically different suggestions as to how a problem is to be handled. I have tried to maintain this sense of conflict in the extracts below, by including (as the Chinese author does) the critical commentaries.
Here, for example, is what the Ji Yin Gang Mu has to say about “Post Natal Aphonia”:
The heart has Seven Orifices and Three Wings. After parturition there is deficiency and often this causes accumulation of poorly functioning blood (败血/bai xue). [If] this occludes the orifice of the Heart, the consciousness (Shen Zhi – lit. “Spirit and Will”) is unable to retain clarity. Again, the Heat qi communicates directly with the tongue. If the Heat qi is blocked then the tongues also stiffens, and thus one is unable to speak. Qi Zhen San (“Seven Pearls Powder”) can be used.
Qi Zhen San (“Seven Pearls Powder”)
Ren Shen 30g (Ginseng, Radix)
Shi Chang Pu 30g (Acori Graminei)
Sheng Di 30g (Rehmannia)
Chuan Xiong 30g (Ligustici Wallichii)
Xi Xin 3g (Asari cum Radice)
Fang Feng 15g (Ledebouriellae)
Chen Shan 15g (Cinnabaris)
The above are finely powdered (deleting the cinnabar is recommended!); the patient takes 3g per dose washed down with Bo He (Menthae, Herba) tea.
By reducing the doses proportionately the formula can be used as a decoction.
Quotes from other books are also included, with their differentiations and various treatments. Following this, a case history is appended:
A woman unable to speak after giving birth. Qi Zhen San was used, to which she responded, but then the mutism recurred, accompanied by internal heat and hot flushes, heaviness and lassitude of the limbs, and she was unable to eat or drink.
Jia Wei Gui Pi Tang was used as the primary formula, with Qi Zhen San included.
Again she recovered, but again relapsed after becoming angry, and this time there also occurred opisthotonos, inability to eat or drink, trembling of the hands and feet, occasional hematuria, redness of the face with alternating tinges of green or yellow. The doctor said: green is the colour of the Liver, while yellow shows Spleen qi deficiency, and red shows Heart blood deficiency. Ba Zhen Tang (“Eight Treasures Decoction” plus Gou Teng, Fu Ling, and Yuan Zhi were used, and she gradually recovered. Jia Wei Gui Pi Tang was used to consolidate the treatment and prevent recurrence.”
The very next section of the Ji Yin Gang Mu discusses “Post Natal Intemperate Speech and Delirium”, which comes closer to what Western medicine would consider the most common manifestations of Post Natal Depression: mood swings and inappropriate emotions.
It describes six pathological mechanisms, each with a number of formulae appended, saying:
There are a number of causes for post natal intemperate speech or behaviour, fainting, or delirium, as if hallucinating ghosts. One must carefully differentiate the symptoms and signs, and use one’s herbs in treatment in an equally cautious manner…
Six Mechanisms of Post-natal Intemperate Speech and Delirium
1. Heart deficiency with accumulated “bad blood”
The first is post natal Heart deficiency with accumulation of poorly functioning blood which rises affecting the Heart. Those who talk deliriously to themselves should be treated as per the “hallucinating ghosts” section; (where is says: the Heart thus affected)… begins to lose touch, and gradually agitation builds. The patient cannot lie quietly, but rather becomes delirious and sees ghosts. A doctor may not recognise this, and take it for pathogenic wind, but treatment for wind will definitely not succeed.
Tiao Jing San (Regulate Menses Powder) should be used each time adding a pinch of Long Nao. When she sleeps she will recover.
Tiao Jing San (Regulate Menses Powder)
Mo Yao 3g (Myrrha)
Hu Po 3g (Succinum)
Rou Cui 3g (Cinnamomi Cassiae, Cortex)
Chao Chi Shao 3g (Paeonia Rubra, Radix, fried)
Dang Gui 3g (Angelica Polymorpha, Radix)
Xi Xin 5g (Asari cum Radice, Herba)
She Xiang a bit (Moschus Moschiferi, Secretio)
Powder finely; take 1.5g per dose mixed in a bit of raw ginger juice and warm wine. Su He Xiang Wan (Liquid Styrax Pill) can also be used.
Teacher Xue says: the foregoing condition should be treated with Tiao Jing San if the cause is poorly functioning blood/bai xue stopping up the Heart orifice. But if blood is weak with deficient fever, then Bao Zhen Tang (Eight Treasure Decoction) plus Pao Jiang (Zhengiberis Officinalis, Rhizoma, fried until popping) should be used. If the Heart blood is depleted, use Bo Zi Ren San (Biota Seed Powder).
Most often this condition is the result of Heart and Spleen blood deficiency. Simply tonify and regulate Stomach qi so that phlegm is cleared and then the Shen/Spirit will naturally compose itself. If she continues to “see ghosts” of ancestors and the like, then moxa the ghost points, which will cure her. If it happens that she is still unable to rise, this is usually due to over-zealous use of phlegm dispelling and fire draining herbs.
Bo Zi Ren San (Biota Seed Powder)
Bo zi Ren (Biotae Orientalis, Semen)
Yuan Zhi (Polygalae Tenuifoliae, Radix)
Sheng Di (Rehmannia Glutinosae, Radix)
Ren Shen (Ginseng, Radix)
Dang Gui (Angelica Polymorpha, Radix)
Sang Ji sheng (Loranthi seu Visci, Ramus)
Fang Feng (Ledebouriella Sesloidis)
Hu Po (Succinum)
Gan Cao (Glycyrrhizae Uralensis)
Equal doses of the above herbs should be roughly ground, then fifteen grams boiled with the strained soup made from a white ram’s heart (sheep will probably do – ed.). This treats postpartum yuan qi deficiency with blood stagnation leading to delirium and hallucinations.
Case history from the Ji Yin Gang Mu
A post-partum woman with the previous condition at first recovered when Tiao Jing San was used, but then relapsed. Again the same formula was used but she became worse, with phlegm welling upward.
In the morning she was cold and in the evening she was hot. I gave her Ba Zhen San (Eight Treasures Powder) in the morning, and Jia Wei Gui Pi Tang (Restore the Spleen Decoction with alterations) in the evening. After fifty doses she was cured.
2. Zang deficiency
The second is deficiency of the zang-organs generally following parturition, allowing the Heart Shen to be easily startled and disturbed so that the consciousness (Zhi Yi – lit. “Will” and “Thought”) becomes unsettled. The speech is chaotic, and the patient is not in control of the feelings (Jue) or perceptions (Zhi). Teacher Xue says: Each person is controlled by the Heart, but the Heart is controlled by blood. As soon as Heart blood becomes weak the Shen has no residence, and this is the cause of the emotional disturbance. Best tonify qi and blood.
Treatment: Gui Pi Tang (Restore the Spleen decoction, Formulas and Strategies, p. 225)
(Also see the 1997 case histories at the end of this article for more on this approach.)
3. Constitutional wind toxin
The third is constitutional wind toxin (Note: this is equivalent to eclampsia). Because in the post natal situation, the Heart is deficient and the qi is weak, the back and lumbar area become stiff, and there may be singing, crying, laughing, and cursing, and the speech generally is disordered. (Treatment not included as this condition is beyond mere post-partum depression).
4. Heart deficiency with exogenous wind invasion
The fourth is post partum Heart deficiency coupled with exogenous wind directly striking internally. The patient is jumpy, easily startled, and disordered in speech and mind. (This is because) qi and blood are closely related to ying/nutritive and we/protective qi, and circulate through the channels to the zang-fu. After parturition, qi and blood are both exhausted, the Five Zang deficient, and ying and wei insufficient to prevent exogenous wind from taking advantage of this situation to invade.
(However) Teacher Xue says: In this condition the main approach should still be enthusiastic tonification of qi and blood, assisted by some of the following formulas. One should know that the “wind” here is actually a false manifestation produced by the extreme deficiency. Strengthen the root source and all disease will recede. If one focuses on “treating wind” the patient will rapidly deteriorate.
5. Delirium and mania from bai xue/bad blood occluding Heart channel
The fifth is delirium from the accumulation of poorly functioning blood following parturition, which occludes the Heart channel and leads to mania, illogical speech without any semblance of normal rationality, or even occasionally coma. The treatment for this is Dou Ming San
Dou Ming San (Snatch Life Powder)
Xue Jie (Draconis, Sanguis)
Mo Yao (Myrrha)
Equal parts of the above are powdered; then boil ½ cup each of good rice wine and children’s urine for 2 minutes. Mix in 6 grams of the powder and take. (Water could be substituted for the urine if desired – ed.). Treats postpartum fainting from (bad) blood entering the Heart channel, delirium, collapse, forgetfulness and loss of will.
6. Exogenous wind-cold invasion
The sixth is exposure to exogenous wind cold following parturition, which leads to reduction and stoppage of the lochial flow, alternating chills and fever in a way similar to malaria, and clear consciousness during the day, but delirium and disordered speech at night.
To treat this, first use equal parts of Sheng Di (Rehmannia Glutinosea, Radix), Shou Di (Rehmannia Glutinosae Conquitea, Radix) and Chai Hu (Bupliuri, Radix) as a decoction. If the symptoms do not disappear, use Xiao Chai Hu Tang (Minor Bupleurum) plus Sheng and Shou Di Huang in the same dosage as the Huang Qin (Scutellariae Baicalenisis, Radix) in the formula.
If the patient acts like she has seen a ghost, then the treatment is similar to that for “heat entering the blood chamber” (re ru xue shi). This should be Hu Po di Huang Wan (Succinum and Rehmannia Pill) plus Si Wu Tang (Four Substances Decoction).
Hu Po Di Huang Wan (Succinum and Rehmannia Pill)
Hu Po 30g (Succinum)
Yang Hu Sou 30g (Corydalis)
Dang Gui 30g (Angelica Polymoursha)
Chao Pu Huang 12g (Typhae, Pollen, fried)
Sheng Di 1kg (Rehmannia)
Sheng Jiang 1kg (raw ginger root)
Extract the juice from the raw ginger and the Sheng Di Huang, then fry together with the pulp. Then powder with the first four ingredients. Use toffied honey to make bullet sized pills. One pill per dose taken wit
Treats Heart blood deficiency with delirium and abnormal behaviour.
One of the “following formulas” mentioned above: Yang Zhi San (Polygala Powder) is as follows:
Yuang Zhi 30g (Polygalae Tenuifoliae, Radix)
Fang Feng 30g (Ledebouriellae Sesloidis, Radix)
Dang Gui 22g (Angelica Polymorpha, Radix)
Fu shen 22g (Poriae Cocos, Sclerotium)
Shou Zao Ren 22g (Ziziphi Spinosae, Semen)
Mai Men Dong 22g (Ophiopogonis Japonici, Tuber)
Sang Ji sheng 22g (Loranthi seu Visci, Ramus)
Ling Yang Jiao 22g (Antelopis, Cornu)
Du Huo 22g (Duhuo, Radix)
Rou Gui 22g (Cinnamomi Cassiae, Cortex)
Zhi Gan Cao 15g (Glycyrrhizae Uralensis, Radix, prepared)
Powder roughly, decoct 15 grams. Note in Ji Yin Gang Mu: “This treats postpartum wind invasion causing disturbed Heart Shen, intemperate speech, delirium, stuffy chest and insomnia.”
This section of the Ji Yin Gang Mu ends with the following interesting statement:
All of the conditions listed above, in both the pre-natal and post-natal sections, each have their individual and specialised treatments established, and these (treatments) are not alike by even a hair. For example, in the post-natal conditions, although the general principal is first to expel the poorly functioning blood and re-establish the new (blood), after this each situation must be distinguished exactly. There must be no reckless invention of new names and categories with the (egotistical) idea of promoting one’s own new system. The formulas, with their appropriate alterations, are (already) set out so as to match the conditions. If one follows the ancient methods in treatment, there are none who will not attain peace.
There is much more in other ancient texts concerning detailed treatments of specific disordered shen conditions, but the foregoing both gives a sample of the flavour of these and provides a source of common herbs used in these conditions.
Acupuncture for postnatal depression
Searching for acupuncture treatments was less successful, however. On checking the Zhen Jiu Da Cheng (The Great Compendium of Acupuncture and Moxibustion) there were only two pages devoted to gynaecological problems specifically, of which the following items may be of interest:
“For all post-natal conditions: Qi-Men (Liver 14)”
“For post-natal syncope and inability to recognise people (including vertigo, fainting, sensations of fullness in the chest, nausea and vomiting, and even disturbed consciousness): Zhi-Guo (SJ 6), Zu-San-Li (St 36), and San-Yin-Jiao (Sp 6).”
There is quite a bit under “Delirium and Mania” which would probably be used in this regard, but nothing there specified “Post Natal”. So it is fairly safe to say that the description and treatment of “Post Natal Depression”: as a syndrome (even though split into its various symptomatic categories) is not traditionally considered the province of acupuncture. Instead they looked to its sister department of traditional Chinese medicine – Chinese gynaecology, which primarily uses herbs.
This does make sense because, as we have seen above, a major physiological component of post-parturition conditions is blood deficiency, and speedy restoration of a deficiency of a substance like blood usually requires herbs (whereas a deficiency of qi, which is insubstantial – ie non-material – could more quickly be rectified with needles).
The fact that Qi-Men (liv 14) is chosen as the point for post-natal conditions in the zhen Jiu Da Cheng demonstrates recognition of this. The Liver channel encircles the groin, and Liver stores blood, so if one wishes (albeit generally) to “expel the old blood in order to restore the new”, needling at the front mu-point of the Liver is the best place to start. This will move qi to remove old blood, while allowing any new blood stored in the Liver to come into play.
For the scholar, seven other texts also list Qi-men as the quintessential post-partum acupuncture point. The Jia Yi Jing (The Systematic Classic of Acupuncture and Moxibustion) is the most explicit:
For women with postpartum disorders, such as inability to ingest food or drink, stuffing fullness in the chest and lateral, costal region, visual dizziness, cold feet, difficult urination, lancinating heart pain, frequent retching, sour foul smell, bi aching (of the limbs), and abdominal fullness which is more conspicuous in the lower abdomen, Cycle Gate (qi Men, Liv. 14) is the ruling point.
[Quote from Yang and Chase translation, p710]
Modern Australian case histories
The following are two case histories that presented in July 1997 with post0natal depression. Both are described for contrast. However the similar mechanisms underlying these cases is, I believe, the most common seen in clinic in post-natal depression cases.
Gillian (name changed) is a 35 year old woman whom I have treated for various conditions, including an episode of recurring panic attacks, over the last ten years. I had seen her in early pregnancy for a cough and flu, but now her son was 3 months old, and she reported that recently she was suffering tiredness, poor appetite, and loose stool.
What concerned her most however was a panic attack that caused vomiting and loose stools, occurring 7 weeks after the birth. She still suffered from insomnia due to breastfeeding schedules but also because of recurring thoughts and racing mind.
The fact that this had occurred 7 weeks after the birth, rather than immediately following, puzzled me briefly, until a minor inspiration struck. With as much aplomb as possible, I asked “So when did you get the period?” she looked surprised and said “at eight weeks. But how did you know?”
The reasoning was simple, in hindsight. Since the Heart shen requires blood as nourishment to maintain its equilibrium, the immediate cause must be lack of blood.
Usually this will be the result of the birth, but here it only manifested almost two months later. Something had to have drained the blood, and the most obvious was an early period (anywhere from three to nine months after the birth is considered normal in TCM). Since the digestive system is obviously weak, it could not keep up with the demands of both breastfeeding and a period occurring together (“breast milk is simply transformed menstrual blood”).
“Hold on, you rascal!” I hear readers saying. “she got the panic attack at 7 weeks, but only got the period at 8 weeks. How do you explain that?” well, a period does not occur from nothing – blood must accumulate below “in the Chong and Ren” in the time preceding. This furthermore drains the blood stored in the Liver, which impairs its function of qi movement and reduces the assistance Liver provides Spleen and Stomach, resulting in the disruption of the ascending and descending function of these organs.
Treatment was based on Gui Pi Tang (Restore Spleen Decoction), adding Ban xia (Pinelliae Ternata, Rhizoma) to assist Stomach descent, Chao shan Yao (Disoscoreae Oppositae, Radix, friend – see “preparation” later this issue) to consolidate Spleen, and Jie Geng (Platycodi Grandiflori, Radix) ad Tong Cao (Tetrapanacis Papyriferi, Medulla) to assist milk flow.
Dion (name changed) is a 32 year old woman who had been referred four years ago by her G.P. for endometriosis and infertility. She became pregnant on her very first batch of herbs, and so not surprisingly returned when she wanted to have another baby. This time it took three batches of herbs to become pregnant (good thing its not always this quick or your beloved editor would be on the dole!).
One week ago Dion came back, 11 months pos-partum, having been diagnosed with post-natal depression in April this year. The symptoms, which started six months after the birth, were fear, agitation, crying, and severe mood swings; an she had been hospitalised and placed on four medications: Zoloft (sertralin hyfrochloride, an anti-depressant), diazepam (anti-anxiety), temazepam (sedative), and haloperidol (an anti-psychotic). Needless to say, she could not drive to her appointment.
Presently, although emotionally more stable on these drugs, Dion still woke with anxiety attacks and a sensation “like a baby kicking”. She said she was ‘terrified that I can’t control my body’, and felt exhausted and cold. Her appetite had been poor since an early pregnancy episode of untreated hyperemesis; she had lost weight and could only eat bland food.
Her eyes felt tired and sensitive to glare. The two periods so far had been heavy with lots of clotting, but both pulses were weak. The right pulse was deep and thready, the left pulse indistinct. The tongue was pale red with a think coat, but also a mild tremble.
Although Dion’s goal was to get off the drugs, we agreed that a foundation of physiological stability had to be laid before this could happen. The immediate diagnostic decision involved determining the significance of the heavy clotting during the periods: was blood stagnation a major factor, or secondary? The key to this lay in the pulses.
Both pulses were weak, but the left was especially so, its indistinctness showing extreme blood deficiency. There was no sign of the choppiness tha would show blood stagnation. Without blood, the shen is vulnerable, under-nourished and unable to stabilise itself. The reason for this, as in the first case history, was the weakness of the digestive system, and the heavy periods she had had so far.
So where did the clotting come from?
Dion had always been cold. This lack of yang and the exhaustion were sufficient to explain a slowdown of blood circulation leading to clotting, and thus the stagnation was secondary and not primary (since the stagnation itself cold not have explained the tiredness, coldness and the weak pulses).
Initial treatment therefore focussed on deficiency, warming and replenishing qi and blood. Shi Quan Da Bu Tang (All-Inclusive Great Tonifying Decoction, Formulas and Strategies, P. 260) was chosen as the primary formula, with aspects of Gui Pi Tang (Restore the Spleen Decoction) added:
Ren Shen 9g (Ginseng, Radix)
Fu Ling 15g (Poriae Cocs, Sclerotium)
Dang Gui 9g (Angelica Polymorpha, Radix)
Zhi Huang Qi 12g (Astragali, Radix, prepared)
Yuan Zhi 6g (Polygalae Tenuifoliae, Radix)
Mai men Dong 12g (Ophiopogonis Japonici, Tuber)
Bai Shao 12g (Atractylodis Macrocephalae, Rhizoma)
Shou Di 9g (Rehmanniae Glutinosae Conquitae, Radix)
Sha Ren 3g (Amomi, Fructus et Semen)
Rou Gui 3g (Cinnamomi Cassiae, Cortex)
Chao Gan Cao 3g (Glycyrrhizae Uralensis, Radix, baked)
Raw ginger 2 slices
Red dates 4
100mls AM & PM
Four bags, when the herbs are finished, take Shi Quan Da Bu Wan, 10 pills AM and PM. Next appointment in three weeks. Do not go off present medication.
The prescription for Dion obviously is focussed on replenishing rather than calming, with emphasis on restoring the digestive ability to provide the long-term blood supply so crucial for shen stability. This foundation must be laid sometime, and it is far better to do it now while she has the support of the Western medication. In this way one can optimise the effects of both systems of medicine. As for the clotting during the periods, this should be reduced by the enhancement of the movement of yang qi provided by the ginseng, ginger, and cinnamon, as well as the blood-moving Dang Gui. When the clots decrease, the loss of blood during the periods will be reduced, and this by itself will reduce the demand on the digestive system.