Depression,anxiety and acupuncture

Depression, Anxiety
Acupuncture
Edited and produced by the Acupuncture Research Resource CentrePublished by the British Acupuncture CouncilFebruary 2002 The Evidence Series of Briefing Papers aims to provide a review of the key papers inthe literature, which provide evidence of the effectiveness of acupuncture in thetreatment of specific conditions. The sources of evidence will be clearly identifiedranging from clinical trials, outcome studies and case studies. In particular this seriesof briefing papers will seek to present, discuss and critically evaluate the evidence.
This paper presents a summary of the evidence for the effectiveness of acupuncture in thetreatment of depression and anxiety. The available sources provide some evidence thatacupuncture is an effective treatment for these conditions. Whilst the results of the trialsand outcome studies are consistently favourable, variability in the type of acupuncture andmethodological shortcomings in trial design make any further conclusion difficult.
Introduction
Research suggests that 1 in 4 people will experience some kind of mental health problemin the course of a year (Bird, 1999). Anxiety occurring together with depression is themost common form of mental distress in Britain, according to the Office for NationalStatistics (ONS, 1995). Results from their 1995 survey suggested that 7.7% of the adultpopulation of Britain suffer from combined anxiety and depression at any one time. Inaddition, 3.1% of adults were found to experience generalised anxiety disorders (notincluding depression), and 2.1% suffer from depression (without anxiety).
Anxiety is defined as a persisting state of fear that may or may not be associated with aspecific object or situation, often accompanied by physiological changes such as a fastheartbeat and rapid breathing. Sufferers experience significant social or occupationalimpairment. Contemporary Western psychiatry defines major depression as a persistingpattern of severe depressive episodes, with an episode defined as a severely depressedmood for at least two weeks, accompanied by at least four additional symptoms including:changes in appetite, weight loss or gain, sleep disturbance, fatigue, feelings ofworthlessness or guilt, difficulty thinking, suicidal thoughts (Flaws, 2001). Majordepressive disorder is also known as unipolar depression to distinguish it from bipolardisorder, or manic depression. The causes of depression have also been used as a basis forclassification, with “reactive” depression occurring as a reaction to stressful life events(also known as “minor” depression), and “endogenous” depression describing caseswithout an external cause but arising from changes in the brain.
The total cost of mental health problems in England has been estimated at £32.1billion(Patel and Knapp, 1998 as quoted by the Mental Health Foundation: Bird, 1999). A 1993study estimated that depression alone costs £3 billion each year in England when lostproductivity and the cost of welfare benefits are taken into account, with the direct cost to Acupuncture Research Resource Centre and the British Acupuncture Council the National Health Service estimated at £420 million per year (Kind and Sorenson, 1993).
Psychiatric medication is the most commonly used treatment for mental illness,accounting for one quarter of all drugs prescribed by the NHS (Bird 1999). In England, theuse of anti-depressants has increased dramatically recently: between 1990 and 1995, thenumber of prescriptions for anti-depressants rose by 116%, with prescriptions for newerantidepressants (serotonin re-uptake inhibitors such as Prozac) rising by 732% (Bird,1999).
Acupuncture has long been used in the treatment of psychiatric disorders in China.
Documentation of their traditional diagnosis and treatment can be found in the Handynasty classics of the Huang Di Nei Jing and the Nei Jing. Psychiatric treatment in Chinahas more recently shifted towards the adoption of modern Western psychiatric methods,while acupuncture trials commonly combine Western diagnosis with the acupuncturetreatment. The Chinese research cited in this paper employs the American PsychiatricAssociation’s Diagnostic & Statistical Manual, 4th edition (DSM-IV), and tend to use thebiomedical model of neurotransmitters and brain chemistry rather than the traditionalChinese medical paradigm. With the advent of electro acupuncture, Chinese doctors arenow using techniques that span the ground between modern Electro-Convulsive Therapy(ECT) and traditional acupuncture techniques.
The therapeutic effectiveness of acupuncture in the treatment of mental distress isbecoming more widely known in the west. In the context of drug addiction complicated bypsychiatric disturbance, modern auricular acupuncture treatment is playing a vital role inprisons, rehabilitation centres and mental health day centres across the country.
Depression itself is one of the 10 most frequent indications for the use of complementaryand alternative medicine (Astin 1998), and ever-increasing numbers of mental healthservice users want access to complementary therapies. A recent Mental Health FoundationSurvey found that 85% of those asked had found different types of complementary oralternative therapies to be extremely helpful, with a high proportion of the sample wantingthe opportunity of trying other forms of therapy (Faulkner, 1997).
Literature Search
A search was made of the ARRC’s database (primarily acupuncture and Chinesemedicine-related records from AMED and MEDLINE) using the key words “depression”(& depressive etc), “anxiety”, “affective”, “bipolar”, “mental disorders”, plus“acupuncture”. Several other references came from searching sources not found in thesedatabases: conference proceedings (Hougham, 1997), university dissertation (Johnson,1992, which led to Riederer et al, 1975), internet site (Flaws & Lake, 2001) and personalcommunication (Allen et al, 1998). Articles were included in the review if they describedoriginal clinical studies of acupuncture (involving insertion of needles, or electroacupuncture) for anxiety and/or depression and were written in English (though oneGerman paper with a full English abstract was included: Eich et al, 2000). The followingwere retrieved: seven controlled trials, four uncontrolled trials, and one case study. One ofthe controlled trials (Riederer et al, 1975) was primarily concerned with investigatingneurophysiological aspects of acupuncture but has been included because it also made aclinical contribution. In the context of understanding the physiological mechanismsmention is also made of the pioneering work by Han in Beijing (Han, 1985).
Acupuncture Research Resource Centre and the British Acupuncture Council Controlled Trials
A summary of the seven controlled trials identified in the literature search is given inTable 1 A groundbreaking pilot-study from the University of Arizona (Allen et al, 1998) deservesparticular mention for its ingenious and progressive trial design. The Arizona researchteam managed to study the treatment of major depression using traditional, individuallytailored acupuncture treatment, within the structure of a double-blind, randomised,controlled trial. The study assigned patients to three groups, the first group receivingacupuncture treatment specifically for depression. The individual diagnoses were madetransparent and accountable through a manual, produced beforehand, and used by theassessing acupuncturist to create a treatment plan according to the presenting TCMsyndromes. Four acupuncturists blind to this process then administered treatment. Ratherthan using “sham” acupuncture as a control (with its unknown non-specific effects), onecontrol group received “non-specific” treatment for something other than depression (e.g.
back pain). The acupuncturists themselves were blind to the condition they were supposedto be treating, and so applied themselves equally when needling both specific and non-specific groups. The second control group was made up of patients on a waiting list fortreatment.
After eight weeks the specific acupuncture group had improved by 11.7 points, the shamacupuncture group by 2.9 and the no-treatment control by 6.1, on a depression rating scale.
Furthermore, when the two controls were subsequently given specific acupuncture, inweeks 8-16, they proceeded to improve at a similar rate to the original specific group, withthe result that, at the end of the study, 64% of the women were judged to be in fullremission from their symptoms. The only mystery in this trial was the rate at which thosepatients on the waiting list improved (intermediate between the specific and shamacupuncture groups), although when they went on to have the specific acupuncturetreatment, they improved at a still faster rate. Since this trial was published, the authorshave brought out a book (Allen & Schnyer, 2001), which provides a step-by-stepmethodology for evaluation and treatment of depression by acupuncture, using theprotocol as tested in this trial. A full-scale trial is also currently underway at the Universityof Arizona.
A trial from the Department of Psychiatry at the University of Mainz (Roschke et al,1999)also asked whether acupuncture could treat people severely affected by a major depressiveillness. Using a more standard design (randomised, single-blind, controlled with “sham”acupuncture), this trial measured the efficacy of acupuncture applied in addition to drugtreatment. 70 hospital in-patients were divided into 3 groups with all groups receiving theantidepressant Mianserin. The first group received medication only; the second alsoreceived “true” acupuncture treatment 3 times a week for one month (point prescriptionBl15, Bl17, Bl18, He7, Pc6, St40, Sp5, Sp6, Lu1 with “a few minutes” needle retention);the third group received sham acupuncture given by “merely pricking” the skinsuperficially “in the neighbourhood” of the point. Two independent judges blind totrue/sham conditions, used 3 different rating scales to assess results. The results showedthat patients treated with acupuncture experienced a significantly higher therapeuticbenefit than patients receiving antidepressant medication alone, but there was nosignificant difference in the benefit experienced by the true acupuncture group comparedto the sham group.
Acupuncture Research Resource Centre and the British Acupuncture Council Another German trial (Eich et al, 2000) used a randomised, sham-controlled double blinddesign. 43 patients with minor depression and 13 with generalised anxiety disorders weredivided into true and sham acupuncture groups. The true group were needled at Du20,Ex6, He7, P6 and Bl62 and the sham group at sham acupuncture points (details notknown). Although after 5 treatments the two groups were responding similarly, after 10treatments a significant improvement was experienced by those receiving trueacupuncture, with a remarkable reduction in anxiety symptoms. These results raise thequestion whether the number of acupuncture sessions might be an important factor intherapeutic success, as well as suggesting that the specific choice of points is an importantfactor (in contradiction to the findings in Roschke et al, 1999). This was judged (Fialka-Moser, 2000) to be a good quality study, but, as with the previous one, there remainsubstantial doubts: the validity of sham acupuncture as a control, the numbers of subjectsand (Eich et al only) the mixing of subjects with two different diagnoses.
A series of trials from the Institute of Mental Health at Beijing Medical Universitycompared the treatment of depression using electro acupuncture (EA) to treatment with thetricyclic antidepressant amitriptyline (AM). The results are consistent: that EA is aseffective as AM in the treatment of depression, and even more effective in the alleviationof symptoms of anxiety, without the side effects of drug treatment.
The first of the Beijing trials (Luo et al, 1985) randomly assigned 47 patients withdepression to 2 groups. One group received EA at points Bai Hui (Du20) and Yintang forone hour per day, 6 days a week, for 5 weeks. The control group received daily doses ofAM. The patients were interviewed weekly by 2 psychiatrists, who were tested regularlyfor congruity and consistency of ratings. The authors classified therapeutic effect by amethod commonly practised in China according to four categories: cured, markedlyimproved, improved and non-improved. 70% of the acupuncture group were deemedeither cured or markedly improved, compared to only 65% of the medication group. Inaddition, except for a slight soreness at the point of stimulation, the patients receiving EAdid not suffer any side effects, whereas the AM group experienced side effects ofdizziness, fatigue, palpitations, dry mouth, constipation.
Acupuncture Research Resource Centre and the British Acupuncture Council Table 1: Controlled Trials of Acupuncture for Depression/Anxiety
Inclusion
Treatment
Acupuncture
Assessment
Criteria
frequency
Major depression Non-specific 12 sessions Depression Rating Scale sham acupuncture (-2.9) & non- Melancholia Scale (BRMS), antidepressant alone, but no LI4, St36, Liv3 combined Biochemical composition of with “generally effective blood and urine studied pre- In the wake of this study, Professor J Han (Han, 1985) set about investigating the effects ofelectro acupuncture on the neurotransmitters commonly implicated in depression and anxiety,focussing his measurements on serotonin (5-HT) and norepinephrine (NE). By measuring theeffects of EA (via St36 or Sp6) on rats and rabbits Professor Han found an explanation for thefindings of the trial above, that EA accelerates the synthesis and release of 5-HT and NE inthe central nervous system. A previous trial in Vienna in 1975 (Riederer et al, 1975) hadfound that needling specific acupuncture points (Liv 3, St 36, LI4) effected change in theamounts of particular neurotransmitters found in subjects’ blood and urine. The authorsremark in passing that subjects of the trial experienced improvement in their depression but,although this was apparently a sham controlled trial, details of the clinical aspects are tooscanty to support a firm conclusion. Professor Han himself concludes that because EA is lessdamaging than ECT (and thus accepted more readily by patients), and just as effective astricyclic medication, it should be considered as an alternative, or at least an adjunct topharmacological treatment.
Following the smaller trial in 1985, EA was again compared to AM treatment in anambitiously large RCT across 9 Chinese provinces (Luo et al, 1990). 241 hospital in-patientsexperiencing depressive psychosis (mostly the depressive phase of manic depression, somereactive depression) were divided into two groups using the same methodology as the 1985trial, although this time the acupuncture group was also given placebo capsules. The resultswere similar: EA was found to be just as effective as AM in the treatment of the depressivephase of manic-depression, either short- or long-term (follow-up was over a two to four yearperiod, although only given for 148 of 241 patients - with no explanation). Patients sufferingfrom reactive depression and anxiety responded even better to EA than AM in therapeuticeffect. Again, a high percentage of the AM group experienced side effects not present in theEA group.
Another Beijing Medical University trial (Yang et al, 1994) compared the use of moretraditional acupuncture techniques against AM in the treatment of depression (both uni- andbi-polar). 41 patients were randomly assigned to either acupuncture or AM groups. Thefocus of the acupuncture was the extraordinary vessels, and points along the Du channel(Du12, Du14, Du20 and Du24) and the Ren channel (Ren14 and Ren17) were needled alongwith GB20 and P6. Du20, Du24 and GB20 were electrically stimulated in all patients. Thesepoints were supplemented with points based on differentiation of the presenting TCMsyndromes (examples given are Stagnation of Liver Qi with Spleen Qi Deficiency, Stagnationof Liver Blood, Spleen and Kidney Yang deficiency, Heart and Spleen deficiency).
Acupuncture treatment was given 6 days per week for 6 weeks. The control group were given25mg AM per day, which was gradually increased to between 150 and 300 mg (according toside-effects and depressive state). Progress was assessed using the Hamilton DepressionRating Scale once per week. The results again confirm the findings above, that acupuncturetreatment is as effective as AM in the treatment of depression and even more effective foranxiety symptoms. It is noteworthy that the more traditional mode of treatment used here isable to match the therapeutic results of the EA in the trials above.
The Chinese trials have been criticised (Stevinson, 1999) for the lack of a sham acupuncturetreatment and hence the inability to separate off the non-specific effects. “Traditional” acupuncturists, on the contrary, tend to favour a more pragmatic version of the randomisedcontrolled trial, where normal clinical acupuncture treatment can be compared to a/thestandard medical treatment rather than to a version of itself. The arguments on this issue havebeen presented in previous papers in this series. Only one (Yang et al, 1994) of the threeChinese studies can be said to have used “normal clinical” acupuncture, if this is taken toinvolve individualised diagnosis and point selection. If a standardised approach is to be usedthen the rationale for the formula chosen should be clearly set out and well rooted (literature,peer consensus). None of the Chinese or German trials referred to here give any reference forthe basis of their point selections (although the predominantly German language paper (Eichet al, 2000) may contain this information).
Methodologically the Chinese trials may suffer with respect to the blinding of the assessors(no information given except for Luo et al, 1985) but they do nevertheless add a substantialamount to the evidence in favour of acupuncture’s effectiveness in depressive illness.
Outcome Studies
A summary of the outcome studies identified in the literature search is given in Table2.
A study from Michigan (Chen, 1992) investigated the use of electro acupuncture on 85patients suffering stress-related chronic illness complicated by reactive depression. Physicaldiagnoses were varied: headache, backache, arthritis, asthma amongst others were included inthe study. Treatment was administered using the authors own method of “Sequential ElectricAcupuncture” (SEA), where the patient is instructed to meditatively follow the sensation ofacupoints electrically stimulated in sequence (20 minute sessions once per day, lessfrequently as condition improves). Points used for depression included Du20, Yintang, GB20,P6, He7, St36, Sp6 and Ki3. Acupoints for the physical disorder were added according toTCM pattern discrimination. Patients used a self-assessment scale designed by the author inaddition to two other standard depression scales. 77.1% of the sample found that theirdepression had improved, with 78.8% experiencing improvement in their physical disorder.
The author concluded that his method of SEA released cerebral serotonin, which providedboth anti-depressant and analgesic effects. He reported that many of the patients were able todiscontinue use of their anti-depressant medication. Whilst this study provides somesupporting evidence of acupuncture’s effects on depression, the sheer diversity of thedisorders treated, as well as the lack of any external assessment, make for fairly flawedevidence. Also, whilst encouraging patients to actively participate in the process of relaxationmight be sound clinical practise, it does muddy the results by introducing non-specific effectsfrom conscious relaxation.
A study from China also investigated the effects of acupuncture on reducing anxiety anddepression in patients with chronic physical illness, where the psychological state of thepatient was exacerbating their physical condition, contributing to a "vicious circle" ofdeteriorating health (Dong 1993). 68 patients were treated specifically for anxiety and/ordepression using “standard acupuncture points” based on differential diagnosis (no furtherdetails given). Anxiety and depression rating scales were used before and after treatment.
One month after treatment anxiety had decreased to normal levels in 70% of the sample, anddepression in 90%. Although this study focused on acupuncture’s effectiveness in treating thepsychological state to contribute to physical wellness no mention is made of concomitantchanges in physical symptoms.
A pilot study in the East End of London (Hougham, 1997) focused on acupuncture provisionat two mental health day centres. Patients were given 8 acupuncture treatments and asked,“What effect has acupuncture had on your overall health?”. To gauge perspective, theacupuncturist and the client’s key-worker were also asked to evaluate the effect of thetreatment using a similar scale. The patients receiving the acupuncture were impressed withthe treatment, and found that it had effected a “marked improvement” in their condition. Theacupuncturist and key-workers agreed more modestly that there had been a minorimprovement. Whilst the numbers involved in the study are low, and the study not audited byan external assessor, the results reflect a very positive reception of traditional acupunctureprovision in mental healthcare services.
A recent user-led investigation into the effects of auricular acupuncture on women with long-term mental health problems found that treatment not only produced clear benefits in terms ofmental health, but also positive effects and outcomes in other areas of their lives such assleep, confidence and motivation (Miller, 2001). Once again this is a very small study (11patients), so the results should be viewed with considerable caution.
Case Studies
Rampes et al (1996) published a single case study of a 33-year-old English woman withgeneralised anxiety disorder who received six weekly acupuncture treatments (points Liv3,Sp6, St36, TB16, Ren13, with electric current applied to LI4). The General HealthQuestionnaire and Zung Self Rating Anxiety Scale were used at baseline, 8 weeks, 3 monthsand 6 months. By the end of the course she was almost symptom free and continued toimprove throughout the 3 month and 6 month measurements. The authors felt convinced thatthe acupuncture had a specific therapeutic benefit, and whilst being aware that non-specificfactors of placebo and sitting quietly every week may have had an effect, they express theirhope of acupuncture’s future role in psychiatry. It is interesting to note that the therapeuticsuccess in this study was achieved through a short course of weekly treatments, as is usuallythe case in private practise in the west.
Table 2: Outcome Studies of Acupuncture for Depression/Anxiety
“Sequential Electric Acupuncture” for 20 mins daily. Points for depression included and Ki3. Points for the physical disorder “Standard” acupuncture points based on differential diagnosis (no further details Five Element based traditional acupuncture Detoxification Association) 5 point protocol Conclusion
The findings from these studies suggest that acupuncture could play a significant role in thetreatment of depression and anxiety. The papers included here show acupuncture consistentlyeffecting significant improvement in these conditions. Fortunately for research-purposes, anumber of internationally recognised observer-rating scales for anxiety and depression havebeen created, which are used in both western and eastern trials to define inclusion criteria andto assess progress. However, variability in the type of acupuncture used in the trials raisesquestions. There is a significant difference between electro acupuncture using two points onthe head, as used in two of the Chinese trials, and the traditional 5-element-based,individually-tailored treatments used by Hougham (1997). Indeed, the former, despite itseffectiveness, bears little resemblance to acupuncture as practised by most members of theBritish Acupuncture Council. It may communicate as much about the therapeutic effects ofelectricity as it does about acupuncture.
The results from the trial of Roschke at al (1999) raise the usual questions about shamacupuncture (for example, to what extent is it an active treatment rather than a placebo), butthe other German RCT manages to demonstrate superiority of the real over the sham version.
In truth, neither study was large enough to provide other than suggestive evidence. TheArizona trial design is exemplary in successfully navigating the problems which typicallyhamper acupuncture research (how to ensure an appropriate control group, how to providedifferential diagnosis whilst maintaining controlled conditions, and how to successfully blindboth practitioners and patients to treatment). A full-scale trial run along similar lines iscurrently in progress in the US and, given the scale of mental health problems and theencouraging results found so far with acupuncture, others will surely follow.
There has been little serious investigation into the longer term effects of acupuncturetreatment of chronic mental health conditions. There are two aspects to this: a) building-in sufficient follow-up assessment after the completion of a trial. The large Chinese study (Luo et al, 1990) commendably instituted a two to four year follow-up, butapparently retrieved only 60% of the subjects. Most studies have had no such follow-up.
b) considering whether continuing treatment is needed on a medium to long-term basis, and if so, what the nature of such a regimen might be. This is not an area where RCTs havetrod, nor are likely to do so: a wider research approach would be required.
Grateful acknowledgement is made to Daniel Maxwell and Mark Bovey for their work inpreparing this briefing paper. References
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