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Affective Mood Disorder
by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)
Of the hundreds of people who attend my Ayurvedic clinic
in Colorado each year complaining of chronic illness, at least half mention
recurrent or longstanding depression as a major symptom. Even of those
who do not complain of depression, Ayurvedic pulse diagnosis frequently
reveals a vitiated sadhak pitta (the fiery humor of the brain
and heart), indicating that low-grade depression is present. Amongst theses
depressed patients, some are suffering from an affective mood disorder,
whilst others have a physical imbalance such as hypothyroidism, giving
rise to the symptoms of depression. Elucidating the causes of depression
and determining the most effective treatment strategy is a daily source
of challenge and fresh learning opportunities.
Cause
of Depression
Within Western psychiatry, depression is typically categorized as reactive
or endogenous. Reactive depression arises in response to a distressing
situation, such as bereavement or a major accident. Endogenous depression
or manic depressive illness is classically said to arise spontaneously,
independent of external causes. In Ayurveda, both reactive and endogenous
depression are considered to result from disturbed or vitiated doshas
in the brain. When the vitiation reaches a certain level, depression inevitably
results with or without external causes. Even when the provoked doshas
in the brain are not at a sufficient level to trigger an endogenous depressive
situation, they still predispose the person to develop depression in the
face of major trauma. Were the prana vayu, sadhak pitta, and
tarpak kapha, which vitalize, energize and nourish the brain, at
normal, healthy levels, external disasters would be met by sorrow or anger
but not by a depressive illness.
Any of the three doshas can give rise to depression.
VATA-TYPE
DEPRESSION
Causes
The prana vayu in the brain and heart can be provoked by a variety
of factors, including terrifying experiences, especially when these occur
during childhood, excess travel, and irregular lifestyle, lack of sleep,
excess talking, excess use of the telephone, spending long hours at a
computer, habitual consumption of dried, frozen, or microwaved foods,
living or working in an air-conditioned room. Both recreational and prescription
drugs provoke the prana vayu, particularly cocaine, amphetamines,
speed, weight loss drugs, caffeine, and antihistamines (including ephedrine;
ma huang). Working night shifts is another important cause of vata-type
depression.
Symptoms
Vata-type depression presents with many of the symptoms of “agitated
depression.” There is tremendous anxiety, guilt and paranoia, irrational
fears, phobias, and catastrophic ideation. Insomnia or restless sleep
is a classic feature of this type of depression. Either the person lies
awake all night, or they fall asleep in the earlier part of the night
only to awaken in the small hours at the vata time of night, obsessed
by fear and anxiety, with the heart pounding. Thoughts ramble endlessly;
there may be terrifying nightmares. Speech is incoherent, the beginning
of a long, rambling sentence being forgotten before the end is reached.
The person is easily distracted, restless, unable to concentrate, forgetful,
and spaced-out. They will not deliberately try to harm themselves but
may forget to eat; indeed, the main hazard in treatment is that they will
be unable to take their herbs regularly and so will fail to improve.
PITTA-TYPE
DEPRESSION
Causes
Violence, ambition, and intensity are the root causes of disturbed sadhak
pitta in the brain. Almost invariably, the problem begins in childhood.
If the child is verbally abused or treated violently, if there is violence
in the home, on the streets, or at school, if angry words are exchanged
between the parents on a regular basis, the sadhak pitta will
inevitably be provoked, laying the foundation for pitta-depression
later in life. Critical, judgmental, driven, ambitious or domineering
parenting styles also provoke the sadhak pitta of the child,
resulting in anger tantrums, low self-esteem, and a lifelong tendency
to depression. Thus provoked, sadhak pitta is handed down from
generation to generation.
Alcohol, a very pitta substance, serves to increase the violent and abusive atmosphere of the home, and adult children of alcoholics almost inevitably suffer from some degree of pitta-type depression. White sugar is extremely intense and is a poison for all children, particularly for the pitta child. Excess consumption of white sugar during childhood (including the use of sweetened infant formula) can predispose a pitta child to severe depression later in life. Excess studying, overwork and driven, ambitious behavior are results of a pitta-provoking parenting style and a further cause of pitta-type depression if it is pursued in a goal-oriented manner. Therefore, Ayurveda advise that we meditate selflessly, with no idea of getting anywhere, with no craving for results. Another significant cause of pitta-type depression is lack of sunlight, and exposure to fluorescent lighting. Abuse of alcohol, marijuana, and/or opiates is both a symptom and cause of disturbed sadhak pitta.
Symptoms
Pitta-type depression is characterized by anger and irritability.
In some cases, the person is not aware of being depressed, but is obviously
angry and very easily irritated, irrational, and perhaps violent. In other
cases, the depression is so deep that anger is not apparent, but if the
mind stream is carefully examined, the thoughts will be found to be angry
and violent. There may be extreme self-criticism and low self-esteem;
or the critical, judgmental tendencies may be directed outwards. Suicidal
ideation is a frequent symptom of pitta-type depression. This
is the most dangerous type of depression, self-destructive behaviour such
as abuse of drugs and alcohol, are a common symptom, serving greatly to
exacerbate the problem. Even those with pitta depression who
are not overtly suicidal often commit slow suicide by inducting conditions
such as hepatic cirrhosis.
Insomnia is a symptom of pitta depression, but is of a different character than vata insomnia. The pitta depressive lies awake between the hours of ten and two, thinking about their burdensome responsibilities and engaging in self-critical, self-destructive ideation.
KAPHA-TYPE
DEPRESSION
Causes
The tarpak kapha in the brain is vitiated by lack of stimulus.
Children who are left in institutions and are not provided proper stimulation
soon become lethargic and apathetic, displaying a kapha-type
of depression. Sleeping in the daytime, sleeping excessively, overeating,
and excess consumption of oily, heavy foods and desserts can contribute
to the provocation of tarpak kapha. Excess television watching
and lack of vigorous exercise are other important factors. Frequently,
kapha-type depression originates in homes in which parents themselves
have some degree of kapha-type depression. The child is encouraged
to overeat, gain excess weight, and stuff emotions. There is an overwhelming
atmosphere of heaviness, emotional denial, and holding onto things. The
parents give food and material goods instead of genuine love, and the
child learns to become greedy, lazy, and attached to food, money, and
possessions. These basic tendencies of greed and attachment, passed on
through the family tree, cause taprak kapha to vecome increasingly
provoked.
Use of "downers" such as sleeping pills, sedatives, tranquilizers, and alcohol, serve to further exacerbate kapha-type depression within the entire family unity.
Symptoms
Kapha-type depression is characterized by heaviness, lethargy,
apathy, dullness, and excess sleep. Frequently, the condition may be masked
as an eating disorder. Patients with kapha-type depression rarely
present to an Ayurvedic physician complaining of depression, as they are
typically in deep denial and are unwilling to take on the self-healing
responsibilities of Ayurveda. However, they may, and frequently do, present
with obesity, and obesity-related problems, such as arthritic hips. Face
reading and pulse reading reveal depression, deep-seated grief and attachment.
MIXED
TYPES OF DEPRESSION
Mixed types of depression involve a combination of symptoms. For example,
a person with vata-pitta-type depression lies awake all night,
is both irritable and agitated, both paranoid and suicidal. These people
are quite likely to actually commit suicide, due to the combination of
vata’s guilt and paranoia, with pitta’s self-destructive tendencies.
Pitta-kapha-type depression shows a combination of irritability
and lethargy. It causes the individual to lie awake at night and sleep
by day. Vata-kapha depressives are spacy and apathetic. They
are very unlikely to commit suicide – indeed, they are unlikely
to do anything at all that requires resolve, and they may be totally unable
to maintain a survival situation for themselves. Tridoshic depression
with agitation, paranoia, anger, irritability, and lethargy is the most
dangerous and the most difficult to treat.
Differential
Diagnosis
In all cases of depression it is important to exclude the diagnosis of
personality disorder. People with personality disorders such as borderline
personality disorder and multiple personality disorder are frequently
depressed, or may have an alter personality who is severely depressed.
Making this diagnosis in the context of the doctor’s office requires
a great deal of acumen and intuitive ability. If you feel that something
is not quite right, that the patient is not “all there” or
that during the course of the visit you have been speaking to more than
one person, evaluation by a skilled therapist may be useful. It is essential
to differentiate between depression and a personality disorder, since
depression can usually be effectively cured by Ayurvedic herbs and flower
essences; whilst in the case of personality disorders, Ayurveda provides
valuable adjunct treatments but therapy with a highly skilled and expert
person is the only real cure.
One patient
came to see me, referred by her spiritual director. An attractive young
woman diagnosed with manic-depressive illness, she eagerly showed me charts
of her up and down times. I was surprised to notice that she was cycling
remarkably quickly. In the course of an hour-long visit, I soon noticed
that I was talking alternatively to two people, one of whom was extremely
depressed while the other was excessively bubbly and frivolous, with a
shopping addiction. Right at the end of the visit she suddenly said: “By
the way, doctor, do you think I have manic depressive illness?”
“No,”
I replied. “No. I don’t. I think you have a personality disorder.
There are two of you, the sad person, and the excitable shopper.”
I
saw her eyes light in deep recognition. “Yes,” she said, “It’s
such a drag, isn’t it?”
Both of us knew that the truth had finally been spoken and that she had
been provided with the necessary contacts to work with her condition,
if she so chose.
DIFFERENTIAL
DIAGNOSIS OF VATA-TYPE DEPRESSION
Vata-type depression must be carefully differentiated from vata-type
of chronic fatigue syndrome. This can be done throught taking a very detailed
history, looking to see if any mysterious illness could possibly have
been Epstein-Barr Virus. The diagnosis is confirmed by pulse reading;
vata-type chronic fatigue showing vitiated vata in the
ojas pulse, which is not the case in vata-type depression, a
disorder of the prana vayu.
Intestinal parasites may also present with symptoms of fatigue, spaciness, and poor memory. On questioning, the patient often claims that their digestion is fine. Careful examination of the pulse, tongue, and nails may reveal ridged nails, with white spots, a coated tongue indented with tooth marks, and a weak digestive fire, symptoms of parasites. Normally, after treatment of the digestive disorder, the depressive symptoms vanish.
DIFFERENTIAL
DIAGNOSIS OF PITTA-TYPE DEPRESSION
Pitta-type depression must be differentiated from pitta-type chronic fatigue
syndrome by careful history taking and pulse examination. Vitiation of
the ojas by pitta indicates that the depression is secondary to pitta
chronic fatigue or possibly to even more severe illness, such as leukemia,
which typically presents with exhaustion and depression.
In females, pitta-type depression should be differentiated from pitta-type PMS or hormonal imbalances, since, despite the similarity of symptoms, the treatment is very different. Pitta-type PMS shows more fluctuation throughout the monthly cycle, with a majority of bad days occurring close to the menstrual period.
Vitiated pitta in the liver can give rise to symptoms of irritability and depression, which closely mimic affective mood disorder. Once again, examination of skin, tongue, and pulse reveals the physical problem, showing low liver energy, weak pitta in the liver (ranjak pitta) and weak rakta dhatu, the tissue layer to which liver belongs. Depression of this kind can follow hepatitis, mononucleosis, or exposure to chemicals including oil paints and epoxy resins. Hepatic-type depression is not an affective mood disorder and is treated by cleansing and rejuvenating the liver and rakta dhatu. Frequently there is superimposition of two conditions, since a person with affective mood disorder has often a history of drug or alcohol abuse, superimposing a secondary hepatic-type depression on a primary sadhak pitta disorder.
DIFFERENTIAL
DIAGNOSIS OF KAPHA-TYPE DEPRESSION
By far the most important differential diagnosis of kapha-type
depression is hypothyroidism or myxedema. Physical symptoms, such as poor
condition skin and hair, constipation, and sluggish digestion, may point
to low thyroid function. The kapha depressive is obese due to
overeating whereas the person with a low thyroid is unable to lose weight
despite eating a light diet. Coldness of the skin and slowness of the
pulse may also point to hypothyroidism. For safety’s sake, thyroid
function should be tested in all cases of kapha depression with
obesity, since hypothyroidism is such a potentially dangerous disease.
However, from the Ayurvedic standpoint, blood tests pick up only the more
severe cases of thyroid dysfunction. Even if the tests are normal, if
examination and the neck pulse show kapha imbalance in the thyroid
gland, herbs to rejuvenate the thyroid should be given immediately, and
will usually be found to cure the symptoms of depression.
Treatment
of Depression
The most important herbs for the treatment of depression are: brahmi,
jatamansi, and vacha. In addition, specific herbs are used
in vata-, pitta-, and kapha-type depression.
BRAHMI
Brahmi is by far the most important herb for treatment of affective
mood disorders. Its active principle, hersaponin, regulates brainwave
activity, and aids porductio of malnutrition and serotonin. It contains
iron, riboflavin, vitamin B6 and oleic acid. In the treatment of depression,
brahmi is taken as a tea, on teaspoon steeped for ten minutes
in a cup of boiling water. It should be taken three times daily. At bedtime,
for a more sedative effect, milk is used in place of water. In addition
to brahmi tea, brahmi ghee is used both as a nasya and
as a tonic: brahmi ghee nasya is taken five drops in each nostril
daily; before bed. Brahmi ghee is taken as a tonic, one teaspoon
on an empty stomach, twice daily. Brahmi oil may be made using
either sesame or coconut oil. Brahmi-sesame oil is applied to
the soles of the feet at bedtime and to the forehead, in cases of vata-type
depression, and wil help calm the prana vayu and bring sound sleep. Brahmi-coconut
or Brahmi-sunflower oil is applied to the soles of the feet and forehead
in the case of pitta-type depression, and helps calm anger.
In severe cases of depression, basti is administered regularly, using brahmi decoction and sesame oil. Ayurvedic treatment of depression should not be deemed unsuccessful until brahmi teas, brahmi ghee tonic, brahmi ghee nasya and brahmi basti have been administered for several months.
JATAMANSI
Jatamansi is the Indian variety of valerian, and is a perennial
plant with stems partly underground and a woody root stock, growing about
two feet high. It is the source of the essential oil known as nard or
spikenard, as is highly aromatic. Bitter and astringent by taste, cooling
in energy and sweet in post-digestive effect, it has a balancing effect
on all three doshas. It nourishes prana vayu, tarpak kapha and
sadhak pitta and is important in treating all kinds of depression.
Currently, the Indian government is not allowing export of raw jatamansi.
It is still possible to obtain nard essential oil and the compound known
as sarsvati, which contains equal parts of brahmi, jatamansi,
and calamus root. Sarasvati, named for the goddess of knowledge
and speech, is valuable in the treatment of depression, an should be taken
as a dry powder, combined with herbs which are of special relevance for
V-, P-, or K-type depression.
VACHA
Known in English as sweet flag, vacha is a rhizome which contains
acorin, the active principle. It is pungent and bitter in taste, heating
in energy, and pungent in post-digestive effect. It calms vata
and kapha, but may provoke pitta, and is contra-indicated
in cases of stomach ulcer and bleeding disorder. It is of great benefit
in V-K-type depression.
VATA-TYPE
DEPRESSION
V-type depression should be treating using brahmi tea,
brahmi ghee, and brahmi sesame oil massage. Sarasvati
should be given, _ teaspoon twice daily followed by warm water. Guggulu
is extremely valuable for fear, anxiety, nervousness and all vata-type
mood disorders. Normally, for vata, it is best given as the compound Yogaraj
Guggulu. If the pitta is high or there is a history
of hyperactivity, the cooler compound, kaishore Guggulu, is used
instead. Due to its scraping effect, Guggulu is NOT used in pregnancy.
Oiling and sweating using brahmi oil will help to calm the prana vayu, as will a treatment known as shirodhara, which consists of pouring a gentle stream of warm sesame oil on the forehead, or shirobasti, in which the entire scalp is bathed in warm sesame or brahmi oil. Basti using brahmi decoction and four ounces of warm sesame oil, is also valuable in calming the vata dosha.
PITTA-TYPE
DEPRESSION
In P-type depressin also the basic teatment consists of brahmi
tea, brahmi ghee, and brahmi-oil massage. Sarasvati
can be used, combined with herbs that are balancing for sadhak pitta.
These include shankapushpi, rose, sandalwood, and lotus. If there
is a history of drug or alcohol abuse, shankapushpi will be tremendously
useful in healing the liver as well as in calming the mind and balancing
the sadhak pitta. For overall balancing of pitta, a
pitta-soothing diet should be taken, avoiding sour, pungent,
salty, and oily foods. Amalaki should be taken at bed time, _
teaspoon steeped for ten minutes in one cup boiling water.
KAPHA-TYPE
DEPRESSION
The same basic treatments are used in K-type depression. Where
there is obesity, triphala Guggulu can be used. Otherwise, Trikatu
can be added to the sarasvati mixture, for a more stimulating
effect. Refraining from sleep during the day and taking vigorous exercise
is essential in the treatment of a kapha-type depression.
Antidepressent
Withdrawl
Frequently, patients who are on antidepressants want to change to Ayurvedic
treatment and discontinue the antidepressants. In all cases, the antidepressants
should be withdrawn very slowly, first reducing the dose amount and then
reducing the dose frequency. Only when the dose has been reduced to one
grain per week can the antidepressant be completely stopped. For example,
one of my patients currently takes one dose of prozac every five days.
This is to avoid shocking the system, since all change provokes vata.
In mild depression, or when antidepressants have been used only for a short time, antidepressants can be gradually tapered off immediately after starting Ayurvedic treatment. In more severe cases or after longer antidepressant use, withdrawal should begin only after one month of Ayurvedic treatment, when it is seen that the patient can comply with the recommendations and is responding to treatment. In suicidal depression, any change from prescription medication to Ayurvedic treatment should take place only with the consent and cooperation of the psychiatrist involved, and then only in a closely supervised situation. It is usually wiser in this case to continue Ayurvedic treatment alongside medication. Gradually, if there is good response to Ayurvedic treatment, the dose of antidepressants may be lowered or eventually terminated.
In cases where a patient with manic depressive illness in on lithium, it is usually safer for them to continue their regular medication, and to take Ayurvedic treatment as a complimentary therapy.
In conclusion,
Ayurvedic treatment is extremely effective in affective mood disorder.
For milder situations, Ayurvedic treatment is more than sufficient. In
more severe cases, due to the life-threatening nature of depression and
the lack, in most countries, of proper Ayurvedic hospitals, it is best
if there is cooperation between Ayurvedic and allopathic physicians.
Affective
Mood Disorder and Spiritual Emergence
In spiritual practitioners, it is important to distinguish between affective
mood disorders and spiritual emergence crisis. Due to a process known
in Buddhist schools of Ayurveda as “ripening karma,” a latent
tendency to any disease can be precipitated by spiritual practice. One
might say that the practitioner is in an accelerated process and is experiencing
several lifetimes of karma in a few years. In this case, all normal symptoms
of affective mood disorder will be present, and both antidepressants and
Ayurvedic therapy will produce the expected result. It is important to
encourage the person, repeatedly, that what seems to be misfortune is
a ripening of karma and a sign of spiritual progress. Also, according
to Ayurveda, the unwholesome karma can be alleviated by accumulation of
merit, through action such as feeding the poor and performing or sponsoring
rituals; specifically, Vedic fire ceremonies. A Vedic astrologer can be
consulted to determine the specific rituals to be done in each instance.
In other cases,
however, the process of spiritual emergence itself can be misdiagnosed
as an affective mood disorder. A rapid transition form one level to another
can be accompanied by a tremendous release of energy, which might be misunderstood
as a manic or hypomanic state. A slower transition to a new and higher
level of consciousness is often marked by a “dark night” experience,
which may be misinterpreted as clinical depression. The following features
distinguish the “dark night” experience from clinical depression:
1) Antidepressants or lithium have no effect or a negative effect
2) While outer-directed life seems gray and devoid of meaning, a sense
of peace is experienced during meditation
3) While the individual may be incapable, despite his or her best efforts,
of performing external activities effectively, he/she is very diligent
in spiritual practice
4) Intense spiritual longing is experienced
In these cases, brahmi tea, brahmi ghee, and brahmi oil are useful in enhancing clarity in meditation and in bringing better sleep. However, the process cannot be hurried. It will take as long as it takes. The only remedies are patience, perseverance, guidance from an authentic teacher and association with other practitioners. The physician should give reassurance that “this too will pass.”
Alakananda Devi
(Alakananda Ma)
is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal
teacher of Alandi School of Ayurveda, a traditional ayurvedic school and
apprenticeship program. She can be reached at 303-786-7437 or by email
at:
info@alandiashram.org.