Exploring the pathogenesis, syndrome differentiation, and treatment of depression from the theory of "earth as pivot with four elements"

The "earth as pivot with four elements" theory posits the spleen and stomach as the pivot governing systemic qi dynamics. It emphasizes the physiological interdependence wherein the spleen elevates clear yang to facilitate the leftward ascent of water and wood, whereas the stomach descends the turbid yin to guide the rightward descent of fire and metal. This mechanism sustains the cyclical flow of qi and blood, preserves yin-yang balance, harmonizes the five zang organs, and stabilizes the spirit. Within this theoretical framework, the core pathogenesis of depression is identified as middle jiao pivot dysfunction and derangement of qi ascending-descending movement. The initial stage is characterized by the spleen failing to elevate clear yang, leading to the constraint and sinking of liver-wood, which manifests as qi stagnation and mental lassitude. This progresses to the stomach, which fails to descend turbidity, allowing phlegm-turbidity to harass the spirit and cause spiritual disorientation. In chronic refractory cases, pivot obstruction results in an intermingling of cold and heat, blocking the qi circle in round and inducing a state of profound spirit disturbance, and it becomes a difficult and intractable situation. Therapeutically, the primary objective is to restore the ascending-descending function of the middle jiao and regulate the cyclical flow of qi. In the early stage, it should warm and activate the middle jiao to awaken the spirit, using Xiangsha Liujunzi Decoction accompanied by Chaihu (Bupleuri Radix) and Baishao (Paeoniae Radix Alba) to regulate qi movement. In the progressive stage, prioritize harmonizing the stomach and guiding turbidity to calm the spirit by using modified Wendan Decoction. In the chronic stage, address the syndrome of upper heat and lower cold with heart-kidney non-interaction with modified Banxia Xiexin Decoction combined with Jiaotai Pill, to balance cold and heat and harmonize the heart and kidney. This approach highlights the restoration of spleen-stomach rotation and its ascending and descending as the key method to reposition the four elements and re-establish physiological qi circulation, offering a systematic theoretical reference for the syndrome differentiation and treatment of depression.