Dai Guo-bin (戴国斌), Liu Xia (刘霞), Chang Xiao-rong (常小荣)

1 School of Acupuncture, Moxibustion & Tuina, Hunan University of Chinese Medicine, Changsha 410208, China

2 Business School, Central South University, Changsha 410083, China

Depression is a negative emotion feeling upset,unhappy and unable to be confronted with external pressure, including both mental and physical symptoms[1]which influence each other[2]. For employees from various fields, workplace is an important source of pressure. Therefore, the correlation between employees and workplace is actually a key factor in causing depression. In the practice of medicine,the physical symptoms hidden behind the depressed mood have gradually emerged[3]; in management psychology, the relation between depression and workplace has also been uncovered[4-5]. Traditional Chinese medicine holds that human body is a part of the whole universe, and advocates to understand the holism of human body from a bigger environment of nature and society. The World Health Organization(WHO) has defined health as a state of complete physical, mental and social well-being. In traditional Chinese medicine, qi is a comprehensive manifestation of the holism of human body[6]. Normal function of qi activity is the key in maintaining the vital activities, and also the motive and expression of emotions. With its major psychological features, depressed or low mood,and clinical manifestations, depression belongs to the scope of depression syndrome in emotional diseases of traditional Chinese medicine, closely related to the abnormal qi activities of Liver Meridian. Meanwhile, the qi of Liver Meridian influences the function of brain in governing the spirit[7], inseparable from the cognition and behavior of individuals[8]. Hence, the depression symptoms can possibly be ameliorated by regulating the qi activities of Liver Meridian and relevant meridians[9-10].Also, the physical, mental and environmental factors of depression can be integratedly revealed from Liver Meridian based on the differentiation concept of traditional Chinese medicine.

Current depression scales invented by the Western world lack of a mind of differentiation and an eye of holism to analyze the correlations among psychological features, physical symptoms and work adaptation in depression. Although the emotion rating scale forGanzangxiangof traditional Chinese medicine[11-13]and classification scale of body constitutions[14]developed by Chinese scholars contain physical and mental symptoms, the emotional cognition and reactions towards the context are not covered. Context is mapped by nature and society on an individual. Every person is in a context at every moment, family or work, and develops emotional interactions with each context. A workplace is comparatively stable, but the pressure and interpersonal communication barriers in work often induce disordered qi activities and have become a crucial reason causing depression[15-16]. By following the international standards in establishing scales, this study aimed to develop a workplace-related Liver Meridiandepression scale, including the workplace as a factor into the traditional Chinese medicine view of holism to survey the relation between Liver Meridian and depression.

1 Compiling of Primitive Scale and Initial Screening

1.1 Compiling of scale

First, NVIVO 11 software was adopted to assort the records associated with Liver Meridian or depression inHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine),Zhen Jiu Jia Yi Jing(A-B Classic of Acupuncture and Moxibustion),Zhen Jiu Da Cheng(Complete Compendium of Acupuncture and Moxibustion),Zhen Jiu Wen Dui(Questions and Answers About Acupuncture and Moxibustion),Bai Zheng Fu(Ode on a Hundred Pathoconditions),Xi Hong Fu(Ode of Xi Hong), andZhen Jiu Zi Sheng Jing(Classic of Nourishing Life with Acupuncture and Moxibustion),and list the main physical symptoms caused by depression-related Liver Meridian qi disorders or by subsequent qi disorders of other meridians, building up an item pool. Together with the item pools of Beck depression inventory (BDI), Hamilton depression scale(HAMD), symptom checklist 90 (SCL-90), Minnesota satisfaction questionnaire (MSQ), overall job satisfaction scale (OJS) and Courtauld emotional control scale (CECS), the item pool was comprehensively reorganized. Corresponding dimensions were then created and 80 items were obtained and classified into the dimensions properly after filtration. Of which, the dimension of Liver Meridian consists of 18 items,reflecting the qi disorders of Liver Meridian; the dimension of relevant meridians consists of 23 items,reflecting the qi disorders of other meridians caused by dysfunction of Liver Meridian; the dimension of basic psychological activities consists of 17 items, reflecting the basic psychological and emotional states of employees; the dimension of work cognition consists of 12 items, reflecting how employees recognize the job;the dimension of emotional reactions consists of 10 items, reflecting the emotional reactions of employees in work context.

1.2 Initial screening of the scale

By using Delphi method, famous domestic traditional Chinese medicine doctors, psychologists and scholars in the field of management were invited to screen the items based on the mental-work behavioral features of depression and the traditional Chinese medicine differentiation of qi activities. Eventually, there were 5 dimensions containing 60 items in the scale: 14 items in the dimension of Liver Meridian, 18 items in the dimension of relevant meridians, 12 items in the dimension of basic psychological activities, 9 items in the dimension of work cognition, and 7 items in the dimension of emotional reactions.

2 Questionnaire and Further Screening

2.1 Determination of the sample

Employees in service were recruited, and those retired or on sick leave were excluded. The participants were required to tell their age on the questionnaire, and those aged over 60 years old or younger than 22 were excluded.

2.2 Distribution and return of questionnaires

Via the online system ‘Wen Juan Xing’, the questionnaire was sent to 240 participants, and 216 of them responded. The return rate was 90%. One questionnaire was completed in less than 90 s, which was considered invalid. Thus a total of 215 valid questionnaires were collected, from 96 males and 119 females, and the valid rate was 99%, representing a content feasibility.

2.3 The second screening of the scale

The SPSS 17.0 version software was used for data analyses, and principal component analysis was taken for exploratory factor analysis. When the items with insignificant correlation coefficients or only containing 1-2 factors were deleted by using varimax rotation method, 44 items were left: 8 in the dimension of Liver Meridian (item 1-8), 14 in the dimension of relevant meridians (item 9-22), 10 in the dimension of basic psychological activities (item 23-32), 7 in the dimension of work cognition (item 33-39), and 5 in the dimension of emotional reactions (item 40-44).

3 Analysis of the Scale

3.1 Analysis of reliability

3.1.1 Analysis of split-half reliability

The general split-half reliability coefficient of the scale was 0.922, indicating the homology of the tested contents and representing a content reliability.

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3.1.2 Analysis of internal consistency

The Cronbach’s alpha coefficient for the five dimensions, i.e. Liver Meridian, relevant meridians,basic psychological activities, work cognition and emotional reactions, was respectively 0.841, 0.842,0.914, 0.836 and 0.839. Taking out any of the items didn’t cause significant influence on the Cronbach’s alpha coefficient of its affiliated dimension, indicating the homology of the tested contents in the five dimensions and also the content internal consistency of the scale.

3.2 Analysis of validity

3.2.1 Validity of contents

This scale was discussed by experts of traditional Chinese medicine, psychologists and experts in management; it co-opted the item pools of well-developed scales; combined the key points in the differentiation concept of traditional Chinese medicine and the features of Chinese enterprise context; it followed a stylized screening. Therefore, it’s believed that the scale should have a high validity of contents.

3.2.2 Construct validity

The construct validity was explained by the correlation of dimensions and principal component and factor analysis.

(1) Correlation of dimensions

b. The correlation of the score of each item and the aggregate score: the analysis suggested that the intercommunity of all the items was 0.474-0.801,significantly higher than the standard of 0.20 brought up by Wu ML[17], indicating that all the items are worth being kept.

(2) Principal component and factor analysis

A total of 44 items underwent the factor analysis.The results showed that Kaiser-Meyer-Olkin (KOM) =0.893, approaching 0.9, andχ2=5345 in Bartlett’s test(P＜0.001), suggesting that the variables had equivalent correlation with each other, proper to be taken for factor analysis. Nine initial factors with characteristic root ＞1 were generated via principal component analysis. The accumulative variance contribution rate was 65.393% and the contribution rate of factor 1 was 28.570%. The structure analysis of the factors was presented by using orthogonal rotation method based on Kaiser’s criterion (Table 1).

Table 1. Orthogonal rotation matrix of main factors of employee’s Liver Meridian-depression scale (trial version)

The cluster analysis showed that factor 1 consisted of 7 items, with a load between 0.693 and 0.855, reflecting the psychological cognition of employees towards work.Thus, this was a factor belonging to the dimension of work cognition. Factors consisted of 6 items, with a load between 0.633 and 0.859, reflecting the basic mental and emotional state, belonging to the dimension of basic psychological activities. Factor 3 contained 5 items,and its load was between 0.637 and 0.738, reflecting the symptoms of liver qi dysfunction. This factor should belong to the dimension of the Liver Meridian. Factor 4 comprised 5 items, with a load between 0.713 and 0.811, manifesting the work-emotional reactions of employees, and it should belong to the dimension of emotional reactions. Factor 5 had 6 items, and its load was between 0.523 and 0.747. This factor reflected the symptoms of other organs related to liver depression.Thus, it should belong to the dimension of relevant meridians. Factor 6 comprised 4 items, with a load between 0.572 and 0.777, presenting the basic mental state of employees, and it should be classified into the dimension of basic psychological activities. Factor 7 contained 4 items, with a load between 0.485 and 0.663,reflecting qi disorders of other organs caused by liver depression. This factor should be under the dimension of relevant meridians. Factor 8 consisted of 3 items,with a load between 0.594 and 0.824. This factor manifested the symptoms of liver qi depression, and should belong to the dimension of Liver Meridian.Factor 9 consisted of 4 items. Its load was between 0.438 and 0.629. This factor reflected the symptoms of other organs led by liver depression, so it should be under the dimension of relevant meridians.

To conclude, factor 3 and 8 belonged to the dimension of Liver Meridian; factor 5, 7 and 9 belonged to the dimension of relevant meridians; factor 2 and 6 belonged to the dimension of basic psychological activities; factor 1 belonged to the dimension of work cognition; factor 4 belonged to the dimension of emotional reactions. The component items of each factor were all reasonable, suggesting that the construct of the scale is accorded to the designed dimensions.Furthermore, each item held a comparatively high load in its affiliated factor while a low load in other factors.Therefore, the workplace-related Liver Meridiandepression scale should have a content construct validity.

4 Discussion

Due to lack of guidance of traditional Chinese medicine holism, the physical and mental symptoms and the influence of context can hardly be covered completely by a measure. Without differentiation concept of traditional Chinese medicine, the items of current depression scales can only integrate the physical and mental fragments via statistical methods, short of theoretical evidence. The relation between Liver Meridian and depression has been accepted by both ancient and modern traditional Chinese medicine scholars[18-19]. The items of physical and mental symptoms and the influence of context in depression can be integratedly covered by the holism and differentiation concepts of traditional Chinese medicine for classification when Liver Meridian is taken as the main thread. Based on such idea and classification, this study compiled the workplace-related Liver Meridiandepression scale, and its reliability and validity had been approved.

Compared to the time of traditional Chinese medicine classics such asHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine),the living environment today in the 21st century has changed tremendously. To achieve the modernization of traditional Chinese medicine, the crucial thing is to integrate the modern living elements and classical traditional Chinese medicine theories, and elaborate the integration via advanced scientific methods[20].Since now work has become an important part of life,people suffer more and more pressure from work.Nowadays, to fully elaborate the contents of pressure,the workplace must be included in the view of holism and differentiation concepts of traditional Chinese medicine. Inspired by which, this study arose as an exploration and attempt. Some traditional Chinese medicine scholars also developed scales based on a traditional Chinese medicine mind. Hu SY,et al[11-13]invented the emotion rating scale forGanzangxiangof traditional Chinese medicine. In the classification scale of body constitutions developed by Wang Q[14], the qi depression constitution was considered to be a special type of constitution, comprising mental and physical symptoms of depression. Based on the depressed mood and qi, the general manifestation of human body, our scale revealed the depression symptoms starting from the qi dysfunction of Liver Meridian. In this scale, the dimension of the Liver Meridian, containing 2 factors and 8 items, and the dimension of relevant meridians,containing 3 factors and 14 items, not only described the physical symptoms caused by Liver Meridian qi dysfunction in depression, but also the physical symptoms caused by qi dysfunction of other meridians influenced by the Liver Meridian qi dysfunction. The dimension of basic psychological activities, comprising 2 factors and 10 items, can elaborate the basic mental state. The dimension of work cognition, consisting of 7 items, described the self-cognition of employees in work context. The dimension of emotional reactions,consisting of 5 items, described the features of emotional reactions of employees in work context.

The nature of market economy decides the objective existence of pressure. Pressure assigned to each employee by the organization has become a crucial factor leading to occupational depression, manifested in every process and part of the workplace, including judgement in making decision, behavioral habits and interpersonal relationships[21-22]. The existence of depression will impair the work satisfaction and happiness of employees[23], leading to slackness and absence in work[24]and increasing the cost of enterprises and society[25-26]. The workplace-related Liver Meridian-depression scale can offer an overall measure of the depression state in employees from physical, mental and occupational aspects, to provide effective intervention and avoid the aggravation of depression[27-28].

Prevention and management of negative emotions such as depression is also significant in augmenting employees’ competition quality[29]. traditional Chinese medicine not only plays a role in preventing and treating diseases, but also in comprehensively and specifically increasing the adaptability of employees because of its concepts of holism and differentiation. It’s very important to turn the possibility into reality in realizing the modernization of traditional Chinese medicine.From the perspective of management, the integration of modern management and traditional Chinese medicine requires both exploration in practice and richness in theory, especially the creativity in methodology and breakthrough in study methods[30-31].As an exploration to comprehensively evaluate the depression state in employees, this study reviewed employees from physical, mental and occupational aspects with traditional Chinese medicine concepts of holism and differentiation, which is also an attempt to break the current study pattern.

Conflict of Interest

The authors declared that there was no potential conflict of interest in this article.

This work was supported by National Basic Research Program of China (973 Program, 国家重点基础研究发展计划, No. 2015CB554502); General Program of National Social Science Fund of China (国家社会科学基金一般项目, No.15BGL104); Open Fund Project of Hunan Provincial Key Discipline of Twelfth Five-year Plan (湖南省“十二五”重点学科开放基金项目, No. 201515).

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