The Treatment of Seasonal Affective Disorder (SAD): Classical Points for a Contemporary Condition
Seasonal affective disorder (SAD), a type of depression, is a debilitating problem that interferes with the quality of life of thousands of patients, especially during the fall, winter and early spring. This syndrome seems to be a worldwide phenomenon and occurs cross culturally, especially in countries far from the equator. Clinical symptoms that reappear regularly with the seasonal changes include lethargy; difficulty concentrating; depression; negative thoughts; elevated cravings for carbohydrates with corresponding overeating and weight gain; hypersomnia (excessive sleepiness); tiredness in the morning; diminished libido; and decreased social interaction. Patients typically become more anxious by the end of the summer as they anticipate the coming months, during which less sunlight is present and their symptoms return.
Clinical experience reveals that patients may have other mental problems as well, such as substance abuse disorders, personality disorders and anxiety disorders, which as comorbdid conditions, further exacerbate the degree of the SAD patient's symptoms. Flaws and Lake define SAD as "a variant of bipolar disorder characterized by cyclic manic, depressive or mixed mood states that are somehow triggered by external clues to changing seasons, including principally, increased or decreased day length. Individuals with SAD tend to become depressed during the autumn months and manic during the springtime."1 This is a complicated disorder that may accompany many severe illnesses such as cardiovascular and endocrine disease, and for which a patient should seek qualified professional help. Seasonal affective disorder does, however, respond well to treatment with Oriental medicine.
My personal approach is to use acupuncture, herbs and lifestyle modifications to address the problem. While there are a core group of symptoms that patients share, each patient has his/her own medical history and clinical manifestations, mental or physical illnesses. If we treat the pattern that emerges - that is, individualize the treatment - best results can be obtained.
There are many acupuncture points from which to choose to construct a treatment, but in this article, I will list some of my preferred points, their physiological energetics and corresponding needle techniques. Before selecting points, however, there are some general guidelines that can help structure the treatments:
Keep treatments simple by addressing the root of the disorder instead of treating symptoms.
Begin treatment at any time; however, the summer is ideal. By doing so, there is a good chance the practitioner can break up the cyclic pattern of symptoms so that they are reduced or even eliminated before the problematic seasons arrive.
Treat the patient 1-2 times a week, depending upon which interval works best for them and in light of the degree of their symptoms.
Personally, I have found the primary point in the treatment of seasonal affective disorder to be yintang. Yintang is located at the glabella, between the medial ends of the two eyebrows. Deeply, posterior to the pituitary gland, at the base of the hypophysisis lies the pineal gland, which responds to light and seasonal changes. When light levels are low, the pineal gland secretes melatonin, a hormone that it also manufactures, which is involved in the regulation of sleep and mood disorders. It has the effect of sedating the body and promoting sleep. Hence, during seasons of low light, the pineal gland constantly produces melatonin and a sleepy state is induced. By needling yintang, the pineal gland can be stimulated such that both lethargy and depression are decreased. Insert a thin needle such as a 36 gauge, one-inch needle through the point by threading it subcutaneously downward at a depth of 0.3-0.5 in. Moxa is contraindicated. If inserted painlessly and accurately, patients love the effect of this point. Many patients have reported to me that they believe it has changed their mindset and alleviated depression, allowing them to be more relaxed yet invigorated. One patient I recently treated effectively with SAD referred to this as the "heaven point" as soon as I would needle it.
Liver 3 (taichong) is known as a primary treatment point to redress the Liver, which can easily be put out of balance due to its crucial role in the body as the mediator between the internal and external environments. As the shu stream point, Earth point and yuan source point, Liver 3 stabilizes, nourishes and grounds the Liver. It regulates the zang-fu organs, quiets the mind, and makes the spirit peaceful. While many clinicians think of Liver 3 for moving Liver qi stagnation, it is actually better to adjust the relationship between the usual clinical scenario of Liver yang rising and Liver yin deficiency. Liver 3 is a primary point for nourishing Liver yin, and thereby moving stagnation by building yin versus simply moving stagnation alone, which is only appropriate for excess conditions. I prefer threading Liver 3, 0.3 in. proximally, or even connecting Liver 2 (xinjian), the sedation and fire point, to Liver 3 when signs of Liver fire such as agitation, mania, insomnia or signs of heat/fire are present. Locate both points in their standard locations. The needle insertion in the direction of the meridian is a tonification technique. Use a 36 gauge, one-inch needle and treat bilaterally.
GV 20 (bahui) is another important treatment point. As a sea of marrow, it awakens and strengthens the brain. It pacifies the spirit, clears the mind and stabilizes the will. It spreads Liver qi and, in cases of excess, subdues the Liver. Needle the point in a tonification direction, i.e., anteriorly toward the face. If manic or fire symptoms predominate, needle the point in a sedation direction, that is, opposite the flow of the meridian, downward and toward the back of the head.
CV 4 (guanyuan), located 3 cun below the umbilicus along the midline of the body, is a central point to treat the Kidney, Liver and Spleen. It is referred to as the crossing point of the Kidney, Liver and Spleen meridians on the abdomen; that is, it is analogous to SP 6 (sanyinjiao), the group luo of the 3 leg yin. It builds the Kidney; adjusts the qi; builds blood; and strengthens the foundation of the body. Puncture perpendicularly 0.5-1.2 inches with a fine #1 (36 gauge) 1-1/2-inch needle and obtain a mild stimulus. Moxa is also applicable for long amounts of time and frequently, as long as the moxa is not contraindicated (i.e., no signs of yin xu with heat/fire or excess heat).
Kidney 3 (taixi) is another excellent point to include in the treatment of seasonal affective disorder. Kidney 3, like LR 3, is the source point of the meridian and as such is useful in the treatment of chronic disorders and those that can benefit from accessing the prenatal jing of that meridian. Kidney 3 is also the shu stream point and Earth point of the Kidney meridian, thereby balancing both Kidney yin and yang.
According to the Chinese doctors with whom I studied in Beijing, Kidney 3 has four major functions: it tonifies Kidney qi (i.e., the yin and yang) and tonifies source qi, blood and essence. They also maintained that KI 3 is better than SP 6 to tonify yin and water, while SP 6 is better for yin and dampness. Kidney 3 replenishes Kidney yin when it is deficient, especially when there is a hyperactivity of Liver fire. Kidney 3 strengthens the brain and willpower, the lack of which is a deficiency manifesting as depression.
Figure 1: Chinese and Japanese point locations of Kidney 3.
The standard Chinese location of KI 3 is in the depression between the medial malleolus and tendo-calcaneous, level with the tip of the medial malleolus. If selecting this location, puncture perpendicularly with a #1 (36 gauge) one-inch needle, insert shallowly, and obtain a mild stimulus to tonify Kidney yin. A sensation radiating to the bottom of the foot is useful. Moxa is applicable. I prefer to needle the Japanese location of the point, which is identical to the Chinese location of KI 5. This point is called Japanese KI 3. It is defined as one cun directly below Chinese KI 3, in the depression anterior and superior to the medial side of the tuberosity of the calcaneous level with KI 6. Using a #1 (36 gauge) one-inch needle, puncture the point 0.3-0.5 in subcutaneously upward and toward the Chinese location. If you prefer, you can palpate both the Chinese and Japanese locations and select the point to needle that is the most tender. Needle bilaterally. See Figure 1 for the locations of both points.
While there are certainly more points which could be chosen to treat seasonal affective disorder, this prescription of yintang, LR 3 (taichong), GV 20 (baihui), CV4 (guanyuan) and KI 3 (taixi) is a simple model that works well and brings quick, immediate relief to the distressed patient. Herbal advice is outside the scope of this article but is likewise a valuable, biological supplement to treatment. The table below outlines useful behavioral habits the patient is encouraged to follow that can augment the treatment.
Advice for Seasonal Affective Disorder
With seasonal affective disorder, one may crave carbohydrates in the form of starches and sweets. If needed, consume breads, pastas and pastries made of whole grains instead of white flour. Add more protein to the diet such as nuts, lean meat, fish and small amounts of fat from cheeses or other sources; some fresh fruit; and plenty of cooked leafy vegetables, whole grains and baked vegetables such as yams or baked potatoes.
Exercise regularly by walking vigorously 20 minutes, 5-7 days per week, in the morning or when there is the most sunlight.
Work with lots of light by the windows to allow exposure to natural light.
Avoid overeating or gaining weight. Both will make you more tired and more sensitive and depressed.
Try to go to bed earlier and get up earlier when there are more daylight hours. Avoid naps during the day, which can interfere with sleep in the evening.
Think positive, happy thoughts. Try not to worry or be fearful. Enjoy the warmth of family, friends or any activity that brings "fire" to your life. Encourage the cultivation of joy in the patient's life.
Reference
Flaws B, Lake J. Chinese Medical Psychiatry: A Textbook and Clinical Manual. Blue Poppy Press, Boulder, CO, 2001, p. 449.
As modern medical standardization continues, the field of traditional Chinese medicine has the advantage of comprehensive personalization. For rare or complex cases, deeper consideration of constitution is invaluable. Proper constitutional assessment, especially with first-time clients, can guide desirable and predictable outcomes. This leads to a higher rate of return, and greater trust between you and your patient.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Traditional Chinese medicine and the Vedic traditions both offer rich frameworks for understanding human health, emphasizing the balance of physical, mental, and spiritual aspects. The concept of "souls" or spiritual components in TCM, namely Hun, Po, Shen, Yi, and Zhi, bears significant similarities to the yogic concept of koshas. Their similarities and differences provide insights into how these systems contribute to holistic health practices.
