A Clinical Report on the Treatment of Depression
Jimi Windmills
ABSTRACT
This case report presents the treatment of depression in a male patient in his mid 20's. For the purpose of client confidentiality the patient will be know as Hubert.
Major depressive disorder is a psychiatric mood disorder characterised by depressed mood and loss of interest or pleasure. These symptoms are often accompanied by “significant appetite or weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation (being restless and jittery, or alternatively, slower than usual), fatigue or loss of energy, feelings of worthlessness or excessive guilt, impaired thinking or concentration; indecisiveness, or suicidal thoughts/thoughts of death” (WHO 2011; Fry & Ryan 2007). According to Boon et al., it is twice as common in women than men, becomes more prominent toward middle age, and has a prevalence of between 5-10% of the general population (Boon 2006: 240). Boon et al. also says there are genetic factors that predispose to depression, however these are poorly understood (Boon et al. 2006: 240). It is widely regarded that emotional deprivation and adverse experiences in childhood can also be contributing factors to the subsequent development of major depressive disorder (Boon et al. 2006: 240).
The approach taken in this case was to address underlying deficiencies, while at the same time, disperse excess conditions such as stagnation and phlegm. Given the nature of the condition and the short duration of the treatment, it seems doubtful that a significant long-lasting effect was actually achieved. With particular regard to the patients propensity toward difficult living situations, and lack of supportive relationships in his life this is not surprising. Given the results of the outcome measures however, I do feel that with an extended course of treatment, and more support (particularly stable accommodation) in his life, Hubert could make significant progress toward recovery.
CASE HISTORY
Hubert suffers depression and anxiety. After a certain amount of time, becoming more familiar with Hubert, it became apparent that perhaps his anxiety and depression were part of a larger scope psychotic disorder along the lines of schizophrenia, involving some element of delusion or an inability to completely grasp reality.
Hubert's main complaint was that he felt down, and because of this, was having trouble concentrating. He considered himself a science-fiction novelist, despite the fact that he had never produced any substantial amount of work. In consultations, he made only fleeting eye contact. He was fairly tall and thin, almost to the point of being bony. His hair and skin were greasy, and he had an offensive odour that was difficult to remove from the room after a treatment. His personal hygiene was poor, once telling me that he preferred the cooler climate in Melbourne because he didn't have to shower very often. At the time of his treatments (beginning at the start of August), he said he had been living with his parents since March. He had told them that he was just visiting for Easter, but had stayed longer. Hubert said that his parents were a major source of his mental unease. He said that they persistently bullied him, and that they “rebel against him”. He said they were unhappy having him living at home. Hubert slept all day to avoid conflict with his parents, and would stay awake all night drinking coffee, unsuccessfully working on his novel. I found out in the second consultation that Hubert's father had died of asbestosis 5 years previously. Although he always referred to his “parents” it was actually only his mother that was around. Hubert described a history of emotional abuse from his parents, with his mother becoming the main perpetrator, since the death of his father. In my last session with Hubert, he informed me that he would not be continuing treatment, despite making some progress, as things had become intolerable with his mother, and he was moving back to Melbourne to live in a park. Until this time I had been unaware that before he came to Brisbane in March, he had actually been homeless, living in a park in Melbourne.
In the initial consultation, Hubert reported a gamut of signs and symptoms, making his case seem quite complex.
- Irregular sleeping hours, usually sleeping through the day and being awake all night.
- Sleep regularly disturbed by intense nightmares
- Waking feeling unrefreshed
- Anxiety and depression with pressure/heaviness in the chest
- Pressure in the head, headache front and temporal
- Difficulty concentrating
- Floaters and blurry vision with itchy eyes (for the last few months)
- Tinnitus for years, high pitched in both ears, worse when having difficulties concentrating
- Palpitations and panic attacks with shortness of breath – links to lack of motivation.
- Constant thirst, desire to drink in small sips
- Frustration, anger, and guilt.
- Poor relationship with parents who “rebel against him”
- Difficulty speaking – stutters
- Offensive, almost rancid body odour
- Makes no eye contact.
Tongue: purple body with red tip and sides, wet with a thick coat, and scalloped edges.
Pulse: weak and deep, rapid and wiry.
In the second consultation Hubert reported a general lift in energy and stated that his nightmares were a concern. Hubert said that he had nightmares every night which interrupted his sleep. His main concern was that sometimes, when he wasn't feeling as down as usual, and he felt things were progressing, he would have a particularly disturbing nightmare which would send him spiralling back down into severe depression. He reported that his anxiety was better and that his depression was easing, but that he was feeling a lot of anger. We discussed his relationship with his parents, and the role of their interaction on his mental health. He told me in this session that his father had passed away 5 yrs previously (which roughly coincided with the period of time he had been living in a park). There was obviously grief, and an element of guilt attached to this loss. In this consultation I gave Hubert a SF-36v2 Health survey to fill out, so that we could track and measure outcomes in a more quantitative way.
The third session began with Hubert feeling quite distressed. His mother had driven him into the city, and they had had and argument during the car trip. She had refused to drive him the extra distance to the clinic in Fortitude Valley. So, as well as being angry and frustrated with his mother, he was also out of breath from hurriedly walking the rest of the distance.
He reported that he felt the treatments were helping him a lot, and that aside from his current exasperation from the car trip, he said there had been a “dramatic improvement”. He reported that his dreams, were less frequent, and hardly noticeable, but that frustration was keeping him awake. He said that as I had recommended, he was drinking much less coffee, only 2 cups/day, and none at night, And was drinking more water, tea, and juice. He said that he had been sleeping to avoid his depression and anxiety, and also to avoid his “parents”, and that he was experiencing pressure in the head when he tried to concentrate. In this treatment we exchanged the Ren point pair LU7+KD6 with a Jue Yin point pair, using the earth points on the Liver and Pericardium channels, to nourish at the deepest yin level. By the end of this session Hubert had calmed significantly
Tongue: Thin coat, teeth marks, wet and swollen in the middle.
Pulse: Fast and Wiry.
Hubert's next session was with another student practitioner, to whom Hubert stated that the last treatment he had received had placed “a buffer between him and the people bullying him”. He said he was feeling mostly sad and angry, and was sick of feeling self-pitty. The same treatment protocol was followed in this session to maintain consistency.
In my last session with Hubert he informed me that while he felt he was still up and down emotionally, he felt he had made some improvement. He also said that most of the good work comes undone when he goes home to his “parents”. He told me that since he was no longer welcome at home, and since his mother was so over-controlling, he was going to move back to Melbourne. I asked if he had a place to stay down there, and he replied that there was a park that he lived in for 5 years before coming to Brisbane, and that he felt safe there. I encouraged him to seek out support services in Melbourne to assist him to find accommodation, but he didn't seem very interested in the idea. I also encouraged him to continue his treatments at the Endeavour campus in Melbourne, and arranged to have his file transferred and a treatment concession plan put in place. In this session, roughly a month from our first consultation, I got Hubert to fill out another SF-36v2 health survey. The results of which will be reported later.
TCM DIAGNOSIS AND TREATMENT
In the initial session we diagnosed Hubert as having Liver-Qi Stagnation and Qi xu, with underlying Kidney and Heart Qi xu leading to the heart not housing the mind (shen disturbance).
My initial thought was to treat this case the way it appeared (i.e. symptomatically) by addressing the component dysfunction of the Liver, Kidneys, and Heart. It was then pointed out that the Liver-Qi itself is most likely not the cause of the condition and that treating it would produce little change since it was a product of an underlying condition. To that effect we decided to treat at a deeper level through the penetrating vessel point combination PC6+SP4, along with REN17, 14, and YinTang.
In the second session we re-diagnosed his condition as Heart and Kidneys non communicating with Liver-Qi stagnation and phlegm misting the mind. To his previous treatment we added LU7 for grief, and KD6, since Heart and Kidneys not communicating is a Yin xu pattern. This point pair was also chosen to include the Ren channel in the treatment. ST40 and SP9 were added to address the phlegm. We prescribed the formula An Shen Ding Zhi Wan -
In the third treatment we exchanged the Ren point pair LU7+KD6 with a Jue Yin point pair LR3+PC7, picking the earth/yuan source points on the Liver and Pericardium channels, to nourish at the deepest yin level.
Hubert's final treatment continued with the previously established treatment plan. For Heart and Kidneys not communicating, with Liver-Qi stagnation and phlegm misting the mind. LR3+PC7 (Jue Yin earth) PC6+SP4 (Penetrating vessel), REN14 and 17 for the heart and Qi, and ST40 and SP9 for phlegm and damp, plus a refill of his prescription of An Shen Ding Zhi Wan.
WESTERN MEDICAL DIAGNOSIS
In western terms, Hubert would most likely be diagnosed as having major depressive disorder, as he fulfils the required criteria of having depressed mood, and loss of interest or pleasure, plus several other associated symptoms including insomnia and hypersomnia, impaired thinking and concentration, feelings of worthlessness and guilt, and weight loss. There is also the possibility that he may be diagnosed as having schizotypal personality disorder (SPD). SPD is characterised according to the World Health Organisation, and outlined in the WHO ICD-10, as behaviour and appearance that is odd, eccentric or peculiar, poor rapport with others and a tendency to social withdrawal, odd beliefs or magical thinking, influencing behaviour and inconsistent with cultural norms (WHO 2011).
TREATMENT PRINCIPLE
The initial treatment principle was to Tonify Heart and Kidneys, soothe the Liver and calm the shen. In the third session the treatment principle changed; Tonify and re-establish communication between Heart and Kidneys, resolve phlegm and damp, soothe the Liver and calm the Shen.
OUTCOME AND DISCUSSION
In this case the outcome is unfortunately not clear. Using The SF-36v2 health survey, we measured Hubert's perception of his physical and mental health in the second session, and then again in the last session almost one month later. The results show a clear (and relatively marked) improvement in the patients overall perception of his mental health. There was also a slight decrease in the patients perception of his physical well being. The SF-36v2 is calculated using eight categories, three for physical health three for mental health and two that overlap.
Image 1. shows the eight categories assessed in the SF-36v2
These two graphs show the difference between the patients own perception of his health at the beginning of the second session compared with that after a month of treatment.
We can see here that there is only a small deviation in the first four columns of each chart. These represent Hubert's physical health. There is a small decrease in perceived physical health. The most significant change is seen in the last three columns respectively representing social function [SF], emotions [RE], and mental health [MH]. In these columns we see an increase in SF of 16.3 points, RE of 11.6 points, and MH 8.4 points.
In my opinion achieving these results in the space of one month (five treatments), is an excellent indicator that acupuncture can successfully treat depression and related symptoms.
CONCLUSION
This case report presented the treatment of depression and associated symptoms, using acupuncture and chinese herbs. In the section on outcomes and discussion we can see that there was a qualitative improvement in the patients condition. However, I would not regard this case as a complete success, as there was still a significant way to go before we achieved his health goals of relieving depression and anxiety, and helping concentration. Since Hubert had a tendency toward relapsing back into habitual behavioural cycles, especially those that flourished in the family environment, and his preference to otherwise live in the park (another destructive behaviour), I would be surprised if these outcomes lasted for any length of time. I do believe however, that in the right supportive environment, a patient suffering from a similar condition could maintain significant lasting results.
REFERENCES
Boon, N., Colledge, N., Walker, B., Hunter., J 2006, Davidson's Principles & Practise of Medicine, Churchill Livingstone Elsevier, India.
Fry, R. & Ryan, C 2007, Depression, ABC Health & Well Being, viewed 12 November 2011, http://www.abc.net.au/health/library/stories/2007/06/05/1944066.htm
World Health Organisation (WHO) 2011, Depression, World Health Organisation, viewed 12 November 2011, http://www.who.int/mental_health/management/depression/definition/en/index.html
World Health Organisation (WHO), The ICD-10 Classification of Mental
and Behavioural: Clinical Descriptions and Diagnostic Guidelines, World Health Organisation, p.p. 83-84, viewed 14 November 2011, http://www.who.int/classifications/icd/en/bluebook.pdf
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