Depression & Pregnancy - Female 29

Case History

Patient General Information

Miss J.S. is a Marketing Analyst. She is 29 years old and her main complaint was depression.

Consultation Information

Asking diagnosis: Main Problems

According to the patient, she had been ‘worrying since she was very little’. The first time she recalls having depression was at the age of 16 when her adoptive parents explained to her that she had been adopted and she had a twin brother. Her twin brother had not been put for adoption. She contacted her biological parents. They did not want to have anything to do with her; they even offered her money so that she left them alone. This event triggered the first major episode of depression. At the time her doctor prescribed her beta blockers and sertraline, an antidepressant (BNF, 2008).

Since then she has been subjected to other episodes of depression in her working life. The trigger seems to be stress at work and it appears that the pattern is repetitive. The patient (Miss J.S.) would start a new job, at the bottom of the ladder (low position). Then she would ‘work hard’ and, invariably, her determination, will power and competence would be noticed by her managers and she would get a promotion in six months or less. Afterwards, she would continue to progress in the company and get promoted. Later, she would start feeling stressed at work. She would start ‘worrying’ and having irrational fears then getting depressed, the major characteristic of her depression being irrational fears. The main consequence of this depression would be quitting her current job then being treated by the doctor until she feels better.

 Thereafter the pattern would be reproduced again:

• Starting a new job at the bottom of the ladder because she would not be confident enough to try and apply for a job congruent with her skills 
• Making a fast progression in her career with rapid promotions and having a fulfilling job.
• Hitting a very stressful episode and falling back into depression quitting her job because she thinks that she cannot cope.

Lately she had had psychotherapy. This provided her with tools to analyse her “cognitive patterns of behaviour” and helped her to recognize the irrationality of her fears when they would start “creeping in”. ionality of her fears when they would start “creeping in”.

However, recognizing her fears had not been enough to dispel them. She has been treated by “Bowen technique” a soft tissue remedial holistic therapy (for more information on Bowen technique see (ECBS, 2008) and (BCMA, 2008)). She found Bowen technique very helpful to manage her stress and keep depression at bay. Nevertheless, she would like to “get to the bottom of the problem”. When asked to describe the nature of her worry, she said: ‘like something out there to get you’. When probed, she admitted a feeling of fear of the unknown. This fear increased with stress to the point of becoming uncontrollable. The patient stated that she was better when she felt supported. She also reckoned that the situation would start to change when she could ch 

 Diagnosis by her GP was depression. She has been treated with beta-blockers and sertraline (she took her medicine). However she thought that the medication had a short term effect. She therefore suspected that they were not treating the root of the problem.

TEN QUESTIONS

• Chills and Fever: none
• Sweating: no sweat.
• Head and Body: The patient sometimes has headaches especially when she does not drinking enough water. Headache is not very frequent however, when it occurs, it can be on the nape of the neck. She wears glasses for long distance vision. The patient also has red cheeks.
• Chest and Abdomen: heart burn, acid regurgitation and complained of bad breath.
•  Food and Taste: appetite is good but digestion is not always good - feels bloated.
•  Stool and Urine: bowel movements once a day. Urine seems normal
• Sleep: Normally sleeps from 11pm to 7am. Slept disturbed by nightmares when she is not well (depressed).
• Deafness and Tinnitus: no tinnitus, hearing seems ok
• Thirst and Drink: does not feel particularly thirsty
• Pain: back pain in the kidney area (lower back), frequent twinges. The patient had a terrible back pain when she was 22.
• Gynaecology: c.f. Lifestyle and Medical History

LIFESTYLE AND MEDICAL HISTORY

• Previous medical history: She had repetitive kidney infections three kidney infections lately. Had depression at the aged of 16.
• Family medical history: Biological parents needed IVF (in vitro fertilisation) to conceive. During the third treatment at the CAM clinic, the patient expressed concerns about being able to conceive because she was herself conceived after her biological parents had an IVF treatment.
• Present medication: currently using adrenal supplements, vitamin C and multivitamin supplements
• Lifestyle : The patient expressed that she does not exercise much but she feels better when she does. She feels that she has a wonderful relationship with her partner. She does not smoke and refrains from drinking. She does not eat meat but she can eat fish. She had been separated from her twin brother at birth but she met him in her teens. They get on very well. Her biological parents kept the brother but put her for adoption at birth. When she tried to meet them they did not want anything to do with her and even offered her money in exchange for ‘being left in peace’. This triggered her first major episode of depression. Her life seems dominated by stress, worry and fear. She patient assumed that she had a good diet. However she when asked six weeks after the first consultation to produce a weekly report on her food intake, she exclaimed: “I never realised that I was eating so much junk!”
• Gynaecological History: The patient claimed that she had never been pregnant nor had a miscarriage. Her periods are irregular with a cycle around 5 weeks when she started coming to the clinic. She had not kept a tab on them before and her declarations seemed contradictory from one visit to another.

OBSERVATION DIAGNOSIS

•  Spirit: This patient has spirit (Maciocia, 2004, p. 144)
• Demeanour: the patient looked nervous, unstable and was overwhelmed by the presence of more than one assistant (2nd year or 1st year student observing). Her nervousness disappeared when there was only one assistant.
• Body: The patient looked overweight. She acknowledged that she was overweight and was trying to go more regularly to the gym to shed some pounds.
• Face and Skin: The patient had red cheeks and dry skin
• Others: the patient seemed restless
• Tongue (body and coating): the tongue is purple with thin but greasy yellow coating. It is swollen with teeth marks. There is a crack in the middle of the tongue. Sublingual vein are visible and dark.

SMELLING AND LISTENING DIAGNOSIS

Voice, cough, belching and smell: Voice was groaning, monotonous. Maciocia (1989, p. 153) states that this indicates a kidney disharmony.

PALPATION AND PULSE TAKING

Pulse Taking: The pulse was wiry on the middle position with slippery addition on the right, deep and weak on the third (proximal, kidney) position on both sides, choppy on the first (distal) position on the left and slippery on the first position on the right.

TRADITIONAL CHINESE MEDICAL DIAGNOSIS

SUMMARY OF THE INFORMATION:

Miss J.S. 29, a successful marketing analyst, came to the clinic to get help with her stress and depression. She also suffers from eczema on the upper arm but is not too concerned by it. Her first episode of depression started when she discovered her biological parents and was totally rejected by them at age 16. Her biological parents used IVF to have a child but when they realized that they had twins, they ‘got rid of her’ by sending her for adoption and kept her brother. She reckoned that she had been a worrier since little and later realized that this worry was due to the fear of the unknown. She seemed to have very strong will power which helps her to succeed in her job and get promoted very quickly to managerial positions. However, stress eventually triggers her depression and makes her feel inadequate. She would then quit her job until she gets better. Subsequently she would still lack confidence in her abilities and start looking for a job at a low level of competence.

She has been treated by her GP with sertraline, an antidepressant from the category of selective serotonin reuptake inhibitors with some success. She also tried Bowen technique, which proved useful in managing her stress. However, she wanted to find the underlying cause of the problem and was wondering whether acupuncture could be a better solution. As she was contemplating starting a family in the near future, she feared that she could not continue to use western medicine when she would be pregnant. She did not exercise much but felt better when she did. She had a terrible back pain when she was 22 and 3 kidney infections lately. She still feels a dull (twitching) pain in the lower back from time to time. She feels tired but has no lack of appetite. After analysing her menu for one week, she realised that her diet was poor. She has heartburn and acid regurgitation. When she is not well, she would have nightmares. She also complained of having a bad breath.

She takes vitamin C, vitamin supplements and adrenalin supplements. The pulse is weak and deep on both third positions, wiry on the left middle position. Pulses are also slippery on the right and slightly choppy on the front left position. The tongue is swollen with teeth marks, purple with thin greasy yellow coating especially toward the middle and sublingual vein are visible and dark.

TCM PATTERNS:

The following TCM (traditional Chinese Medicine) patterns have been identified:

• Kidney Essence Deficiency Yin + Yang
• Liver Qi Stagnation
• Liver invading Stomach
• Damp heat in Stomach
• Liver blood deficiency
• Spleen Qi deficiency
• Kidney + heart disharmony
• Blood stasis

The root (ben) seems to be Kidney essence deficiency it is due to hereditary factors exacerbated by chronic fear of the unknown.

Maciocia (1989, p. 132) states that in adults, fear depletes kidney yin and make empty heat rise to the face – hence the red cheeks.

Overwork and overuse of the will power (Zhi) depletes kidney yang and Qi energies. Emotional factors especially stress justify the liver Qi stagnation. Any long-standing emotion or disease will ultimately affect the heart (Flaws, 2004, p. 23).

The branches are liver Qi stagnation, heart and kidney disharmony, kidney Yang and Qi deficiency, damp heat in the stomach.

WESTERN MEDICAL DIAGNOSIS AND TREATMENT

The patient was diagnosed with depression. The main tool used in western medicine for this diagnosis is the DSM IV (Diagnostic and Statistical Manual of Mental Disorders version 4) developed by the American Psychiatric Association (APA, 2004). This tool helps in determining if a patient has a depression and classifying the severity of the depression in order to guide the physician for the appropriate treatment.

Kumar & Clark (2005, pp. 1288-1291) advocate an integrated model of aetiology for depression. In this model, stress is the trigger when the terrain is favourable to depression. This in turn triggers various brain changes in both stress hormones and neurotransmitters. They suggest that a depressive illness involves both the mind and the body, which cannot be separated. Accordingly, the best treatment would be a combination of CBT (cognitive behaviour therapy) and antidepressant. This conclusion is supported by research (Riggs & al, 2007).

In the present case, the GP has decided to prescribe beta-blockers and Sertraline. Beta-blockers have been prescribed to solve a problem of arrhythmia or anxiety (Mayo Clinic, 2008). Although palpitations seem to be masked with the patient, the heart pulse is still choppy indicating that the heart in Chinese Medicine has been affected. Sertraline is a selective serotonin re-uptake inhibitor (BNF, 2008). It seems less toxic than tricyclic antidepressants. However, it has been linked with suicidal and self-harm behaviour in children.

When the patient became pregnant, her GP was not inclined to prescribe antidepressants and suggested that she read a self-help book about depression.

The patient also used Adrenaline supplements. She reports that she felt tired and depressed when she did not use them. It seems that high doses of adrenaline supplements could worsen her condition (Vitamins Supplements Guide, 2005)

Possible treatment methods:

A combination of the following treatments methods will be used. It is not planned to use moxa except on Ren 4, Du 4 and St 36 (if needed)

• Body acupuncture
• Auricular acupuncture
• Advice on diet and exercise

Although electro acupuncture is available, there is no plan to use electro acupuncture for this treatment.

Prescription

• BL 23, BL 52, Du 4, K3, Ren 4, SP 6, Ht 7, P6, Liv 8 (tonification)
• Liv 3, LI 4, (reduction) or GB 40 (even) – either 4 gates or a gall bladder point to help spread the Qi.
• LI 11 (even or reduction)
• Auricular shenmen and auricular heart (even)

Referrals and medication:

The patient is not taking any prescribed medication for the time being. However, she is taking adrenaline supplements, which can cause concern (Kumar & Clark, 2005, p. 976). Adrenaline can induce a feeling of fear or anxiety, tremor, excitability, vomiting, hypertension (over dosage), arrhythmias (especially if patient has organic heart disease or has received another drug that sensitizes the heart to arrhythmias) (Vitamins Supplements Guide, 2005)

Lifestyle issues:

Diet, and a healthy attitude towards work seem to be important. The patient has been provided with advice from (Leggett, 2005) on how to use diet to promote health in terms of food that is :

• good for the essence (such as egg, artichoke leaf, microalgae, and seaweed),
• food to help with Qi (such as lentil, licorice, chickpea, date and fig) and blood (such as beetroot, apricot, kidney beans, sardine, sweet rice and watercress) and
• Food to decrease in order to fight dampness (decrease banana, concentrated orange juice and bread but introduce garlic, onion, anchovy and radish).

A discussion aimed at raising the awareness to the balance between achievement at work and health also took place after 6 weeks of treatment. The patient decided to go at least once a week to the gym.

Treatment Frequency

One weekly session for 10 weeks, then assessment before subsequent treatments. The plan has been agreed by the patient.

Outcome

In the present case, the GP has decided to prescribe beta-blockers and Sertraline. Beta-blockers have been prescribed to solve a problem of arrhythmia or anxiety (Mayo Clinic, 2008). Although palpitations seem to be masked with the patient, the heart pulse is still choppy indicating that the heart in Chinese Medicine has been affected. Sertraline is a selective serotonin re-uptake inhibitor (BNF, 2008). It seems less toxic than tricyclic antidepressants. However, it has been linked with suicidal and self-harm behaviour in children.

When the patient became pregnant, her GP was not inclined to prescribe antidepressants and suggested that she read a self-help book about depression. The patient also used Adrenaline supplements. She reports that she felt tired and depressed when she did not use them. It seems that high doses of adrenaline supplements could worsen her condition (Vitamins Supplements Guide, 2005).

Acupuncture Treatment

Treatment principle

•  Tonify kidney and nourish the essence
• Spread liver Qi and nourish blood
• Calm the shen
• Disperse heat

Outcome

After the first treatment, the patient was delighted. She has been selling both house – her house and her partner’s house - during the week between the first and the second treatment and she did not feel stressed. On treatment 3, the patient complained of feeling sluggish and tired. Stomach 36 was added to the formula for its ability to nourish Qi and blood. It is likely that she did too much the week before and exhausted her reserves of Qi without having an adequate diet. This was 3 weeks before she was asked to produce a retrospective menu – a list of what she has eaten for a whole week. The menu confirmed the assumption: her diet was not adequate. Nevertheless, the patient found that even her eczema was improving.

On week 6, the patient announced that she was pregnant. A risk assessment form was produced by the clinic and added to her file. The patient was informed of the possible risks of acupuncture during pregnancy and asked if she still wanted to continue the treatment. She accepted. The supervisor suggested that we use a minimum number of points. The main complaints to solve were still emotional stability (depression) and morning sickness.

West (2001, p. 30) recommends gentle needle stimulation during pregnancy. Because the patient was the first pregnant client (apart from breech presentation treatments) in the clinic, it has been decided to insert the needle, obtain the de Qi then leave it without further stimulation for 20 minutes then remove it.

Because of the size of the uterus during the first 12 weeks of pregnancy (Verralls, 1993), the use of Ren 12 to harmonize spleen and stomach is appropriate. The points used were Ren 12 and P6 for morning sickness as recommended by West (2001, p. 78) and K3 for the underlying depression (P6 and K 3 bilateral).

The patient explained that she did not have morning sickness for 6 days and she did not feel depressed. However, in order to continue to spread the liver Qi, GB 40 was added to the formula.

Again West (2001, pp. 41-43) was used to provide guidance on nutrition during the first term of pregnancy.

Although the patient was saying during every session that acupuncture was beneficial, she was also concerned by the distance she had to drive to come to the clinic. When she started coming to the clinic, she was living in Wigan. Now, she had moved to Southport 41 miles away, she was finding it hard to drive back home during rush hour on Friday night. She was advised to try to find a BAac registered acupuncturist nearer to home if possible. She stopped coming to clinic after week 9.

PERSONAL REFLECTION AND LEARNING

Acupuncture is a complex intervention (MacPerson & al, 2008, p. 4) . In clinical practice, Ernst (2007) encourages practitioners to take advantage of the placebo effect; he reckons that the ritual as well as the environment surrounding the therapeutic encounter play an important role in the recovery of the patient. “To some, the placebo effect can signal the capacity of the body to heal itself... in clinical practice we might consider maximizing it for the benefit of the patient” (Ernst, 2007).

This looks just like a praise for Acupuncture. Acupuncturists manipulate Qi to help the body heal itself and far from being derogatory, the statement above acknowledges that being able to maximize the capacity of the body to heal itself is a higher form of Medicine.

This has been taken into account in acupuncture practice for long time. For instance, acupuncturists think that the ‘yi’ (intention) of the practitioner is important for the efficacy of the treatment (Hicks, Hicks, & Mole, 2007, p. 40). Moreover, Hicks, Hicks, & Mole (2007, pp. 40-41) insist that the rapport gained with the patient, empathy and compassion along with the state of the mind and the spirit of the practitioner, are crucial factors in the treatment room. The treatment should not be reduced to inserting needles.

Applied to this case, the speed of recovery and the favourable reaction observed could be due to multiple factors, one of which could be the points formula used to treat the patient. Other acupuncture point’s combinations could have been substituted to the formula used. However, the effect of the environment, the care and the time spent listening to the patient might have had an important effect as well.

According to the psychiatrist Hammer (1990, pp. 103-145) the depressive pattern of the patient could be explained by a cyclical over-consumption of her kidney yang energies. One can notice the strong will to succeed of the patient because each time she rapidly climbs the ladder of success when she starts a new job. The will power (Zhi) resides in the kidney it gives single-mindedness in the pursuit of our goals (Maciocia, 1989, p. 74). She would start a new job and the will power mustered in order to succeed would consume her kidney yang and Qi energies. Hammer (1990, pp. 132-133) also states that this Yang deficiency would lead to a feeling of inadequacy and lack of faith in oneself. This is congruent with the patient mental state even when she recovers from depression.

Kidney is the mother of Liver (Maciocia, 1989, p. 21). A deficiency in the mother (kidney) would affect the child and produce a deficiency or weakness in the child (liver).

From the point of view of Five elements constitutional acupuncture we could have treated the patient using only water points – i.e. BL 23, 52, Du 4 and points on the kidney channel because the patient seemed to be of water CF (Hicks, Hicks, & Mole, 2007). Without trying, we cannot predict the outcome. However, during the pregnancy, the patient’s emotional state was stable whilst minimal number of points was used. One interesting point in this case was the reaction of supervisors. Some of them would refuse to treat a pregnant woman and suggested to stop the treatment because of the risks of legal action. Some suggested dialogue and information to the patient who then could make an informed choice. West (2001) suggests that acupuncture could be safely used in pregnancy as long as the practitioner understands the points that are contraindicated. These points are clearly pointed out in Deadman (1998) and supplemented by a good anatomical knowledge of the pregnant woman (1993). This experience could be useful in my clinical practice should a similar situation occurs. The blood stasis component (purple tongue and dark sublingual vein) seems to have been completely overlooked in the treatment. Although it may seem important, it was not a priority in the beginning of the treatment. If the patient had continued coming to the clinic we could have addressed this issue after the 10 weeks review.

Bibliography

APA. (2004). DSM-IV-TR. Retrieved May 6, 2008, from DSM-IV: http://www.dsmivtr.org/

BCMA. (2008). Bowen Technique. Retrieved May 4, 2008, from BCMA British Complementary Medicine Association: http://www.bcma.co.uk/bowen_technique.html

BNF. (2008). BNF. (BMJ Group and RPS Publishing ) Retrieved May 5, 2006, from BNF, British National Formulary : http://www.bnf.org

Deadman, P. (1998). A manual of acupuncture. Hove, UK: Journal of Chinese Medicine Publications.

ECBS. (2008). ECBS The Bowen Technique. Retrieved May 4, 2008, from ECSB European College of Bowen Studies: http://www.thebowentechnique.com/index.htm

Ernst, E. (2007). Placebo: New Insights Into an Old Enigma. Drug Discovery Today , 12 (9/10), 413-418.

Flaws, B. (2004). Curing Fibromyalgia Naturally with Chinese Medicine. Boulder, CO: Blue Poppy Press.

Hammer, L. (1990). Dragon Rises, Red Bird Flies, Psychology, Energy & Chinese Medicine. Barrytown, New York: Station Hill Press.

Hicks, A., Hicks, J., & Mole, P. (2007). Five Element Constitutional Acupuncture. London: Elsevier, Churchill Livingstone.

Kumar, P., & Clark, M. (2005). Clinical Medicine. London: Elsevier Saunders.

Larre, C., & Rochat de la Vallee, E. (1999). Essence Spirit Blood and Qi. Cambridge: Monkey Press.

Leggett, D. (2005). Helping Ourselves, A Guide to Traditional Chinese Food Energetics. Totnes: Meridian Press.

Maciocia, G. (2004). Diagnosis in Chinese Medicine, A Comprehensive Guide. London: Elsevier, Churchill Livingstone.

Maciocia, G. (1998). Obstetrics & Gynecology in Chinese Medicine. London: Churchill Livingstone.

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