Non-pharmacological interventions for depression in Persian medicine

Abstract

Depression is an important medical problem in today's world. Despite its high prevalence, treatment of depression remains problematic, as its cause is still not fully understood. Of the ways recommended to tackle this problem is implementing the potentials of various medical schools. A medical school which has played an important role in the history of medicine in the world is Persian medicine. This study was intended to identify non-pharmacological interventions for depression in the most reliable references on Persian medicine, classify these interventions and compare them with the latest medical findings. The study was set to review the most reliable references on Persian medicine. In addition, relevant keywords were used to search the PubMed and Scopus databases. In Persian medicine sources, melancholia is categorized into three main types. One type is regarded as cerebral melancholia, which resembles modern psychiatry's depression closely. Therefore, some key points put forth by Persian medicine scholars regarding melancholia can be used to answer questions concerning depressive disorders and their etiology and treatment. Although recent studies have confirmed most approaches offered by Persian medicine physicians in ancient Persia, it is imperative to design and conduct clinical trial studies according to these approaches.

INTRODUCTION

Depression is regarded as one of the most important challenges facing medicine in today’s world, as it is an important factor in the reduction of quality of life (Shimizu et al., 2011) and growth of healthcare costs (Luber et al., 2001). It may also cause relapse of cardiac diseases in patients and increase the risks of morbidity and mortality, resulting in a poor prognosis in these patients (Carney et al., 2003; Frasure-Smith et al., 1993; Pozuelo et al., 2009; Rosengren et al., 2004). According to publications of the World Health Organization (WHO), by the year 2020, psychological ailments will become the imminent healthcare priority in countries around the world. The share of depression, as the second cause of debilitation in developing countries after cardiac diseases, is much more prominent compared to other psychological disorders (Murray and Lopez, 1997).

Unfortunately, despite the high prevalence of depression, treatment of this ailment remains problematic, as its cause is still not fully comprehended (Almeida et al., 2012). The correlation between depression and cardiovascular diseases, which has had crucial consequences from relapse of the disease to high mortality rates, is a very important aspect of the problem which has left many researchers puzzled over the last two decades (Blumenthal et al., 2003; Frasure-Smith et al., 1993; Jianget al., 2001; Penninx et al., 2001; Sullivan et al., 2003). This correlation, and the risks it entails, amplifies the importance of rigorous endeavors in the field. A plausible and recommended way to diagnose and treat diseases such as this has been to implement extensive potentials of various medical schools around the globe (Braunwald and Bonow, 2012).

Persian medicine (PM) is a medical school which has played an important role in the history of medicine (Emtiazy, 2012). This school has introduced prominent scholars like Mohammad ibnZakarīyā al-Rāzī (Rhazes), ‘Alīibn ‘Abbās Ahwāzī (Haly Abbas), Hosseyn ibnabdollāh ibnSīnā (Avicenna) and Seyyed Ismā‘il Jorjānī (Jorjani) to the world.

Of the ailments extensively discussed and studied in this medical school is melancholia (mālīkhūlīyā). Melancholia is defined as a disease caused by an alteration in the functioning of the brain and prevents the sufferer from observing common sense and healthy speculation in a way that the patient is afflicted by paranoia, fear, delusion and sorrow, for no apparent reason (Yousofpour et al., 2015). Based on the principles of PM, the general cause of melancholia is known as an abnormal increase of a matter known as ‘black bile’ or ‘atrabile’ in the body. Depending on where this matter is accumulated, this disorder is divided into three general types: cerebral melancholia, mālenkholia-l-marāqqī and systemic melancholia. Many of the signs of cerebral melancholia are similar to that of depression in conventional psychiatry. Furthermore, in the DSM-V TR classification, melancholic disorders are presented as one of the main type of depressive disorders (Kaplan and Sadock, 2010). Taking all the above into consideration, it seems that the two disorders share a common nature. Thus, some key therapeutic approaches assumed by prominent scholars in PM towards the etiology and treatment of melancholia might prove beneficial.

PM scholars have always applied non-pharmacological treatments along with pharmacological ones, and have held them in high regard, to such an extent that some have presented these treatments as the principal therapeutic approach, and have regarded their implementation as undeniably crucial (Avicenna, 1973). This paper reviews these non-pharmacological treatments, in the hope that this data would be subjected to scientific investigation in form of clinical trials.

 

OBJECTIVES

This study is intended to identify non-pharmacological interventions for depression in the most reliable references on Persian medicine, classify these interventions, and compare them with the latest medical findings.

 

METHODS

Methods

The most reliable references on PM were determined on the basis of the following criteria:

Once reliable references were determined, literature search was initiated to collect data in accordance with the following steps:

Furthermore, the following keywords were used to search the PubMed and Scopus databases: melancholia, depression, traditional, medicine, treatment, music therapy, aromatherapy, nutrition therapy, and chromo therapy.

 

RESULTS

Psychological disorders in Persian medicine

In PM, diseases are classified in accordance with the human body’s organs a capitead calcem (from head to toe); no separate chapter exists in PM sources titled ‘psychological disorders’, but upon further enquiry into cerebral diseases, disorders can be found which are described as having been caused by accumulation of putrid humors in the brain. These disorders include: mālīkhūlīyā (melancholia), ro‘ūnah and homoq (mental retardation), mānīyā (mania), dā’ al-kalb (cynanthropy), qotrob (lycanthropy) and sobārā (maniac phrenitis). This group of diseases can be referred to as ‘psychological disorders in Persian medicine’. The last four disorders are generally regarded as types of psychoses (Jorjani, 2006).

Melancholia (definition - types)

Based on the principles of PM, to each organ in the body two of the four qualities of hotness, coldness, wetness and dryness are attributed, which is regarded as the ‘temperament’ of the organ. The function of each organ is in accordance with its specific temperament. For instance, the brain has a cold and wet temperament; this temperament changes if any of these two qualities change. Any alteration in the temperament interferes with the function of the organ, and would result in the occurrence of disease.

Melancholia is defined as a disease which results from an alteration in the temperament of the brain. The quality of wetness in the brain gives way to dryness, hence, the temperament of the brain shifts from cold and wet to cold and dry. This alteration results in a disturbance of its function; meaning that the sufferer is deprived of common sense and healthy speculation, in a way that s/he is afflicted by paranoia, fear, delusion and sorrow, for no apparent reason ((Avicenna, 1973; Yousofpour et al., 2015).

The English word melancholy comes via late Latin melancholia from Greek melagkholíā, a compound formed from mélās‘black’and kholé‘bile’ (Ayto, 2005).

The reason for the nomenclature of this disorder is that its main cause had been assumed to be an abnormal increase in the amount of black bile or atrabile (Avicenna, 1973).

This disorder is classified into three main types, considering where black bile accumulates:

Melancholia and depression

Both melancholia in PM and depressive disorders in conventional psychiatry have different types, the congruence of all of which is in need of further investigations. But the two disorders seem to have a common nature for the following reasons:

A comparison of symptoms of melancholia in PM with major depression on the basis of DSM_V_IR diagnostic criteria is presented in Table 1. Based on this comparison, and as it seems that these two concepts share the same nature, non-pharmacological treatments of melancholia have been extracted from prominent sources in PM. Afterwards, regarding each treatment suggested in PM, conventional scientific databases have been referred to, in order to find contemporary evidence for current usage of such treatments, and possible explanations for validity of their usage.

Table 1.Comparison of symptoms of melancholia in PM with major depression on the basis of DSM_V_IR diagnostic criteria

Non-pharmacological interventions in PM

Generally, scholars have presented the non-pharmacological treatments of depression under the notions of advices and abstinences (dos and don’ts). First, their exact advices are presented and afterwards, the treatments are elaborated, analyzed and classified.

a) Advices

b) Abstinences

 

DISCUSSION

According to scholars in PM, the treatment of depression or melancholia has three main pillars:

Apart from these pillars, points have been listed which can be regarded as the principles of treating this disorder:

It is noteworthy that PM scholars believed that for some types of melancholia in their initial stage, when no putrid matter is yet formed in the patient’s body, there is no need for medication. These cases are treated by management of the cause of the disorder, meaning by implementation of what is today regarded as ‘psychotherapy’. (Abolhassani, 2013; Baker, 2012).

Rhazes in his book Al-Hawi (the Container) presents an anecdote as a case report, and eventually remembrances that apart from this case; others have been treated by ‘psychotherapy’ (Baker, 2012).

Considering that a majority of PM scholars, similar to Avicenna, believe that: “melancholia is, in essence, dryness of the temperament of the brain, and its amelioration is in increasing the engendering of good wet blood using suitable nutrition.” (Avicenna, 1973). And considering the second therapeutic pillar, which is abounding wettening of the patient’s body, it can be said that most non-pharmacological measures, taken by PM scholars to treat depression, fall within the second therapeutic pillar. However, the third pillar has never been neglected, as many of the nutritional recommendations like apple, quince, pistachio, borage, and pomegranate and etc. are cardiac and cerebral tonics.

Classification of non-pharmacological treatments

The non-pharmacological treatments in PM can be categorized in four groups:

Upon reflecting on the four categories, this important point is arrived at, that the scholars’ main point of concentration is the third group, i.e. treating of the quality of the disease. Put in other words: ‘The canonic cure principle for depression (melancholia) is abounding wettening of the temperament.’

Non-pharmacological interventions in PM and current research

The beneficial effects of many therapeutic measures taken in PM have been verified in current research, some of which are presented here:

A quick review of these points shows that treatment is basically the same in both medical schools. Before reaching any clinical conclusion, however, some considerations need to be taken into account;

 

STUDY LIMITATIONS

We kept our search limited to only the most reliable resources on PM as we did not have access to all trusted sources. In addition, electronic databases were searched for only relevant English articles.

 

CONCLUSION

According to the principles of PM, it is crucial to treat patients suffering from depression in the initial stages, as yet no putrid matter has been formed in their bodies, and therefore, they might not be in need of medication. Given that the scholars of PM viewed the essence of depression as preponderance of dryness in the temperament of the brain, their main focus had been on attempering of this quality. Therefore, the canonic treatment of depression has been abounding wettening of the patient’s temperament. It can be said that the majority of non-pharmacologic treatments listed for the management of depression fall within the second therapeutic pillar. However, the third pillar - i.e. strengthening the brain and the heart- has never been neglected, because many of the treatments serve as tonics for the brain and the heart. Based on the points mentioned in the present paper, the authors suggest scientific study and evaluation of the teachings and therapeutic approaches of PM with regards to this disorder.

CONFLICT OF INTERESTS

The authors have no conflicting financial interests.