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.
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.
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.
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.
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.
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 tarpak 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.
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.
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 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 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.
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.
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.
In P-type depressoin 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.
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.
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:
- Antidepressants or lithium have no effect or a negative effect
- While outer-directed life seems gray and devoid of meaning, a sense of peace is experienced during meditation
- 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
- 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."
Peer-reviewed article was first published in the Protocol Journal of Botanical Medicine.
Alakananda Ma M.B., B.S. (Lond.) is a Certified Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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