Nine Traditional Chinese Herbal Formulas for the Relief of Depression
The World Mental Health Survey Initiative showed that the average lifetime prevalence for major depressive episode based on the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV, American Psychiatric Association, 1994) was 14.6% in 10 high-income countries and 11.1% in 8 low- to middle-income countries (Bromet, 2011). However, conventional antidepressants, such as selective reuptake inhibitors of serotonin (5-HT) or norepinephrine (NE), monoamine oxidase inhibitors (MOI), tricyclic antidepressants, or N-methyl-d-aspartate receptor (NMDAR) antagonists, can’t get satisfactory therapeutic effects, and fail to help at least 40% of depressed patients (Simon, 2006).
As reported in a national survey in the United States, a total of 53.6% of patients with severe depression used complementary and alternative (CAM) therapies during the past 12 months, and 66.7% of patients visiting conventional mental health providers for severe depression also used complementary and alternative therapies (Kessler, 2001). Current commonly used CAM for MDD in the United States are omega-3 fatty acids, St John's wort (Hypericum), folate, S-adenosyl-L-methionine (SAMe), acupuncture, light therapy, exercise, and mindfulness psychotherapies (Freeman, 2010).
Besides acupuncture, as a major modality of Traditional Chinese Medicine (TCM), Chinese herbal Medicine (CHM) have been widely used in the treatment of depression, achieving better therapeutic effects than placebo and having fewer side effects than conventional antidepressants. In 2016, Feng, et al. (Laboratory of ethnopharmacology, institute of integrated Traditional Chinese and western Medicine, Xiangya Hospital, Central South University, Changsha, People’s Republic of China) introduced nine common Chinese Herbal Formulae for the treatment of MDD based on the review of previous studies in the ethnopharmacology, phytochemistry, and pharmacology. They are “banxia houpo” decoction, “chaihu shugansan”, “ganmaidazao” decoction, “kaixinsan”, “shuganjieyu” capsules, “sinisan”, “wuling” capsules, “xiaoyaosan”, and “yueju”, as shown in Figure 1. All these formulae are based on the typical principles of TCM treatment for Yuzheng (depression) according to their pharmacological properties and Chinese-syndrome patterns, including soothing the liver, relieving depression, promoting the circulation of Qi, and resolving phlegm. In addition, a considerable amount of evidence-based research for most of these CHFs have been done, meaning the results can be used to guide clinical practice and research in related fields (Feng, 2016).
Figure 1 The nine common Chinese herbal formulas for Major Depressive Disorder.
Notes: (A) Banxia houpo decoction; (B) chaihu shugansan; (C) ganmaidazao decoction; (D) kaixinsan; (E) shuganjieyu capsules; (F) sinisan; (G) wuling capsules; (H) xiaoyaosan; (I) yueju.
Banxia houpo decoction comprises of banxia (Pinellia rhizome) 12 g, “fuling” (Poria) 12 g, houpo (Magnolia officinalis cortex) 9 g, “shengjiang” (Zingiber officinale rhizome) 9 g, “suye” (Perilla folium) 6 g. Chemical constituents include zingiberol, guanosine, rosmarinic acid, magnolol, honokiol, volatile oils (including linalool, citral, nerolidol caryophyllene, bisabolene, caryophyllene oxide, apiole, α- and β-eudesmol, and α-farnesene), polysaccharides. The dosage: decocted in water take orally twice a day.
Chaihu shugansan (CSS) comprises of chaihu (bupleuri radix) 6 g, “chenpi” (Citrus reticulata pericarp) 6 g, “chuanxiong” (Ligusticum chuanxiong rhizome) 4.5 g, “xiangfu” (Cyperus rhizome) 4.5 g, “zhiqiao” (Citrus aurantium fructus) 4.5 g, “shaoyao” (Paeonia radix) 4.5 g, “gancao” (Glycyrrhiza radix) 1.5 g. Chemical constituents include synephrine, paeoniflorin, naringin, hesperidin, neohesperidin, saikosaponin A, glycyrrhizic acid, nobiletin, tangeretin, ferulic acid, gallic acid, oxypaeoniflorin, albiflorin, liquiritin, benzoic acid, narirutin, meranzin hydrate, liquiritigenin, quercetin, benzoylpaeoniflorin, isoliquiritigenin, formononetin. CSS should be used with caution in patients with yin deficiency, can cause nausea, stomach upset, dry mouth, drowsiness, or insomnia. The Dosage: decocted in water or in powder, take orally twice a day.
Ganmaidazao decoction (GMDZD) comprises of gancao (Glycyrrhiza radix) 9 g, “xiaomai” (Triticum aestivum fructus) 9-15 g, 5-7 DZ (jujube [type of date] fructus). Known constituents are glycyrrhizic acid, isoliquiritin, and isoliquiritigenin, plus unknown extracts of three herbs: tritici fructus, Glycyrrhiza, and jujube. GMDZD is contraindicated in cases with excessive “phlegm fire” inside manic-depressive psychosis. Adverse events associated with modified GMDZD include dry mouth, constipation, melancholia, insomnia, irritability, abdominal distension, and acid regurgitation. The
Dosage: decocted in water take three times a day orally.
Kaixinsan comprises of “Rensheng” (ginseng radix and rhizome [GR]), “yuanzhi” (Polygala radix [PR]), “shichangpu” (Acorus tatarinowii rhizome [ATR]), fuling (Poria [PO]). Chemical constituents include 27 ginsenosides, Polygala saponins (arillatanoside A, tenuifolin), terpenoids (tumulosic acid, pachymic acid, dehydropachymic acid), 18 oligosaccharide esters, and other compounds, including 3,6′-disinapoyl sucrose, polygalaxanthone III, α-and β-asarone, and pachymic acid. The dosage: decocted in water take twice a day orally.
Shuganjieyu capsules comprises of extracts of “guanye jinsitao” (Hypericum perforatum) and “ciwujia” (Acanthopanax). Twenty-two compounds were identified by ultraperformance liquid chromatography tandem mass spectrometry in this formula. Side effects: nausea and vomiting, dry mouth, headache, dizziness, nasal congestion, insomnia, poor appetite or anorexia, diarrhea, and constipation. All these adverse effects disappear spontaneously upon cessation of treatment. The dosage: two capsules (380 mg each) orally, twice a day for 6 weeks, is usually recommended.
Sinisan comprises of “zhishi” (Citrus aurantium fructus) 6 g, chaihu (bupleuri radix) 6 g, shaoyao (Paeonia radix) 9 g, “zhigancao” (Glycyrrhiza radix preparation) 6 g. It contains hundreds of constituents, such as gallic acid, oxypaeoniflorin, albiflorin, paeoniflorin, liquiritin, benzoic acid, etc. The dosage: decocted in water or powder form, take twice a day orally.
Wuling capsules is made from the mycelia of Xylaria nigripes (Kl.) Sacc. in People’s Republic of China. Chemical constituents include nucleosides (adenosine, uridine, and guanosine), 5-methylmellein, 5-hydroxymellein, 5-carboxylmellein, and genistein, and 15 amino acids. Cigarettes, alcohol, and spicy or greasy food should be avoided while taking this formula. Side effects including diarrhea, dry mouth, dizziness, fatigue, abdominal discomfort, elevated liver enzymes, constipation, increased saliva, anterior thoracic discomfort, skin rash, and sneezing have been noticed. The dosage: three capsules (0.33 g each) take orally three times daily for 20 days.
Xiaoyaosan (XYS) comprises of chaihu (bupleuri radix) 9 g, “danggui” (Angelica sinensis radix) 9 g, “baishao” (Paeonia lactiflora radix) 9 g, fuling (Poria) 9 g, baizhu (Atractylodes macrocephala rhizome) 9 g, bohe (Mentha haplocalyx) 3 g, shengjiang (Zingiber officinale rhizome) 6 g, zhigancao (Glycyrrhiza radix preparation) 4.5 g. Chemical constituents include gallic acid, catechin, albiflorin, paeoniflorin, liquiritin apioside, liquiritin, ferulic acid, volatile components (Z-ligustilide, palmitic acid, atractylenolide I, atractylenolide II), isorhamnetin. Modified XYS can cause headache, dizziness, fatigue, and mild diarrhea. The dosage: decocted in water or powder form, take orally twice daily.
Yueju comprises of “cangzhu” (Atractylodes rhizome) 6 g, xiangfu (Cyperus rhizome) 6 g, chuanxiong (Ligusticum chuanxiong rhizome) 6 g, “shenqu” (medicated leaven) 6 g, “zhizi” (Gardenia fructus) 6 g. Chemical constituents include gardenoside, ligustilide, α-cyperone, atractylodin. Side effects: gastrointestinal symptoms, such as diarrhea and constipation. The dosage: 6-9 g of the pills take orally twice daily.
These CHFs provide alternative choices in the treatment of MDD. Hopeful in the future, innovative Chinese medicine will bring new antidepressant agents for MDD patients by integrating modern technology with the multitarget and multi-pathway mechanisms found in these traditional CHFs.
Bromet E, Andrade LH, Hwang I, et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med. 2011; 9: 90.
Feng DD, Tang T, Lin XP, et al. Nine traditional Chinese herbal formulas for the treatment of depression: an ethnopharmacology, phytochemistry, and pharmacology review. Neuropsychiatric Disease and Treatment. 2016: 2387-2402.
Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry. 2010 Jun; 71(6):669-81.
Kessler RC, Soukup J, Davis RB, et al. The Use of Complementary and Alternative Therapies to Treat Anxiety and Depression in the United States. Am J Psychiatry. 2001; 158:289–294.
Simon GE, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006;163(1):41–47.
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