Jimi Windmills
Introduction
Depression is a
psychiatric illness that can potentially be very serious. It involves
symptoms like depressed or sad mood, difficulty sleeping or
oversleeping, loss of interest or pleasure in activities, energy
loss, changes in weight, psychomotor changes, feelings of
worthlessness, and thoughts of death or suicide (Wu et al. 2012:
398). It constitutes a major public health problem, worldwide. The
World Health Organisation declared that the burden of depression is
expected to be second only to heart disease by 2020, and by 2030 the
single largest contributor to disease burden (WHO 2012: 14).
Depression includes major
depressive disorder (MDD), minor depression (MinD), postpartum
depression (PPD), antenatal depression, geriatric depression,
childhood depression, vascular depression, organic depression, post
stroke depression (PSD), drug induced depression, and depression
alongside other diseases. MDD is common and is often debilitating.
Prevalence of MDD is estimated to be between 5% and 13% for women and
between 2% and 8% for men. Over 80% of people who commit suicide have
been diagnosed as clinically depressed in the months leading up to
their deaths (Wu et al. 2012: 398). In a clinical setting as an
acupuncturist, a great many patients that we see could be diagnosed
as having some form of depression. Most people have experienced, or
are close to someone who has experienced depression. It is for these
reasons that I have chosen to write here about depression.
I will first conduct a
literature review, briefly outlining a few of the most recently
conducted studies on the treatment of depression with acupuncture. I
will then explore the topic of depression from both Traditional
Chinese Medicine (TCM) and biomedical viewpoints, with reference to
the literature. I will highlight what I believe to be some of the
advantages and pitfalls of acupuncture research as it is currently
performed, and make some suggestions for methodological improvement
that may strengthen future clinical studies into the efficacy of
acupuncture as a safe and effective treatment for depression.
Literature Review
Since
space does not allow for a comprehensive literature review, which is
normally done either as an assignment in its own right, or as part of
a post graduate thesis, I will concentrate my literature review on a
systematic review of acupuncture and depression, and a selection of
randomised controlled trials (RCTs). By searching various databases
as well as google scholar, I found 9 Clinical trials, 6 systematic
reviews, and a few journal articles involving acupuncture and
depression.
The Physiological Mechanism of Acupuncture
for Depression:
Correlating East and West
Recent
studies on the physiological mechanisms of acupuncture suggest that
it mediates signals that regulate the exchange of information through
an interconnected plexus of channels, which restores balance and
enhances adaptability. Acupuncture points can be likened to
integrated nodes in a functional network. Depression and anxiety as
well as other psychiatric symptoms are associated with particular
neurotransmitters, especially serotonin, dopamine, noradrenaline and
an array of endorphin hormones. Depression has also been associated
with a deregulation of the HPA axis1.
Both animal and human studies have shown that acupuncture has a
demonstrable physiological effect and that it may modulate the neural
functioning involved in the pathophysiology of affective disorders.
Acupuncture is thought to influence immune and neuroendocrine
systems, and it may treat depression by balancing levels of
serotonin, noradrenaline, dopamine, endorphins, and glucocorticoids
by stimulating hypothalamic and hippocampic response (Wu et al. 2012:
399).
According
to Wu et al. acupuncture aims to restore health and maintain balance
by stimulating acupuncture points utilising a variety of techniques.
Diagnosing depression in a patient is done by differentiating
underlying physiological and energetic imbalances and targeting
treatment in an individualised way to restore optimal function and
promote adaptability within the body to maintain health (Wu et al.
2012: 398). The TCM practitioner analyses and identifies patterns in
the signs and symptoms gathered from taking a patients personal and
medical history and from physical examination. For different patterns
in the same disease group, different therapeutic interventions would
be applied (Wu et al. 2012: 398).
In
TCM, the aetiology of mental disorders is the deregulation of the
seven emotions, which are joy, contemplation, worry, sorrow, fear,
shock and anger which damage the internal zang-fu. When one of the
emotions becomes excessive, its related zang-fu may begin to
malfunction which can result in mental and emotional disorders as
described in the Nei Jing Su Wen (The
Yellow Emperor's Inner Canon).
According to Veith, excessive anger damages the liver (2002: 42),
excessive joy damages the heart (2002: 119), excessive thinking
damages the spleen, excessive grief damages the lung (2002: 120), and
excessive fear damages the kidney (2002: 120).
In
their systematic review Wu et al. examines the use of acupuncture in
treating a broad spectrum of depressive disorders including; MDD,
MinD, antenatal, PPD, menopause, geriatric, and PSD. Interestingly,
this paper also goes into detail on the effects of acupuncture
augmentation of anti-depressant medication in depression. In general
they find that acupuncture as a stand-alone therapy for the majority
of these disorders to be relatively effective. In the MDD trials
reviewed, while certainly out-performing the 'wait-list' group,
neither acupuncture group (real or sham) performed significantly
better than the other (Allen et al. 2006: 1665-73). Two other trials;
Luo et al. and Brewington et al. found comparable decreases between
electro-acupuncture and maprotiline and electro-acupuncture and
tricyclic amitriptyline respectively (Brewington et al. 1994 and Luo
et al. 1998). A study on acupuncture for geriatric depression
conducted by Pavao et al. investigated acupunctures effect on stress
related psychological symptoms and cellular immunity by comparing
young adults to elderly subjects. Depression, anxiety and stress were
measured using self assessment questionnaires. As well as reducing
depression, anxiety and stress the study demonstrated a raise in
T-cell proliferation. This was especially apparent in the elderly
group. Interestingly, there was no change in cellular sensitivity to
dexamethasone2,
and the outcomes suggest that acupuncture may decrease psychological
distress and cellular immunosenescence3.
A study of post stroke depression compared acupuncture to fluoxetine
and found that they had comparable success rates in treating
depression. However, acupuncture had fewer adverse effects (Li et al.
2011: 3-6). Perhaps one of the most interesting aspects in this
systematic review is on acupunctures ability to mitigate some of the
unpleasant side affects of anti-depressant (AD) medication. As Hu et
al. points out, AD medication can have some pretty appalling side
effects including, but certainly not limited to; nausea, weight gain,
cognitive impairment, drowsiness, insomnia and sexual dysfunction
(2004: 959-65). Acupuncture has proven effective in clinical trials
for managing many of these side effects. Mehling et al. found
acupuncture to be effective in reducing nausea (2007: 258-266), Wang
et at. found acupuncture effective in managing weight gain (2007:
26-27), and both Engelhardt et al. (2003: 343-346) and Kho et al.
(1999: 41-46) found acupuncture to be effective as a treatment for
erectile dysfunction.
Discussion
By
and large, authors of journal articles are overwhelmingly and almost
without exception, in support of the use of acupuncture as an
effective treatment for depression. Unfortunately the vast majority
of systematic reviews and clinical trials find that acupuncture is
only slightly better then pharmaceutical treatment, and conclude that
it is best suited as an adjunctive treatment, to support
pharmaceutical treatment and to offset some of the adverse reactions
to AD medication (Wu et al. 2012: 402).
So
why such a discrepancy between the positive clinical outcomes of
experienced acupuncturists, and the mediocre outcomes of clinical
trials? Journal articles that deal with case studies, case series, or
provide general discussion on the treatment of depression are
generally extremely informative, very well written, and of excellent
quality. This is especially so when it comes to reporting case
studies. The benefit of case studies, is that the author does not
need to adhere to rigorous protocols for treatment and reporting. Nor
do they need to worry about inclusion or exclusion criteria. Patients
each receive individualised differential diagnosis, and are treated
accordingly. This typically results in excellent outcomes for
patients. This is how clinical reporting has been done for the vast
history of Chinese medicine, and is reflective of how patients are
treated in private practise. It can be extremely beneficial and can
contribute valuable knowledge and helps to inform our practise, and
shapes the way we approach the treatment of depression, or any other
condition we may learn about in this way. The downside of this is
that patients who experience little or no beneficial outcome are
rarely reported in case studies. Because of this bias, case studies
are seen to provide the lowest level of the evidence, on the level of
evidence pyramid, and thus are given almost no credence by western
medicine.
Clinical
trials on the other hand, can be very useful in determining the
efficacy of an intervention for a particular condition. However,
there are problems with running clinical trials to evaluate the
efficacy of acupuncture, if the patients diagnosis is performed using
western diagnostic criteria, such as the DSM-IV or the newly
published DSM-V. Inclusion criteria are usually set to include many
patients, who would have vastly different conditions from a Chinese
medicine perspective. Depression, from a TCM standpoint may arise
from a number of very different patterns of disharmony, each with
differing aetiology, pathogenesis and disease courses. In TCM these
would all be treated as unique cases and each of these patients would
be treated with very different sets of acupuncture points. In a
clinical trial evaluating acupuncture as a treatment for MDD for
example, you may have 50 patients in a treatment group, who all have
a western diagnosis of MDD. It is highly unlikely that these patients
would all be given the exact same diagnosis by an experienced
acupuncturist, yet in a clinical trial, they are all treated with the
same set of points, which may be reasonable as points to treat a few
of the participants, but for the majority of the participants, are
going to be completely inappropriate to treat their pattern of
depression. To illustrate this, here is a list of different patterns
of depression according to Giovanni Maciocia; Deficiency of heart and
spleen, heart and kidneys not harmonised, deficiency of heart and
gallbladder, liver and kidney yin deficiency with liver yang rising,
deficiency of kidney essence, yin deficiency with empty heat,
phlegm-heat harassing upwards, liver qi stagnation, qi stagnation
giving rise to heat, heart fire, blood stasis and stomach-qi not
harmonised (Maciocia 2009: 353).
This
is the nature of set point-protocol style clinical trials, and in a
lot of cases this may be responsible for what seems like a poor
response by patients to acupuncture, when in reality it speaks more
to that fact that the study was poorly designed and the diagnosis of
the patients was not adequately performed to be able to provide them
with an appropriate treatment. This would be similar to taking 50
patients all with different types of cancer for example, and giving
them all the same dose of generic medication, then concluding that
the medication was ineffective as a cancer treatment, because only a
few of the participants in the trial experienced any sort of benefit.
Because
of the flaws in the current trend of clinical trails and evidence
based medicine, acupuncture will find it difficult to really
distinguish itself as an excellent stand-alone treatment for the
large number of conditions, that we as acupuncturists know respond
exceptionally well to the treatment we provide. There are other
issues with the current system of double-blinded placebo controlled
RCTs that make it a poor methodological choice for acupuncture
trials. Placebo and sham acupuncture are very poorly performed in the
majority of trials. Double blinding is essentially impossible. The
acupuncturist performing the treatments in the trial can always tell
the difference between a sham, non-penetrating needle and a real
needle that penetrates the skin, thus there is no blinding of the
practitioner. The counter-productive effects of using sham
acupuncture are well known to those who research sham and placebo
methods, as Hennessey states;
Acupuncturists
eager to demonstrate the effect of their procedures complied to the
rules for doing a random controlled trial, inventing the sham
acupuncture intervention, so that they could do blind studies like
the mainstream researchers and statisticians who dominate the world
of university medical research. In many studies this approach seems
to have worked against them. Studies were not big enough, or sham and
true acupuncture performed at statistically similar levels,
demonstrating insignificant benefits from true acupuncture (2012: 6).
Using
non-acupuncture points as placebo is also obvious to the
practitioner, as is using points that you would not normally use in
patterns of depression, since when stimulating the skin you cannot
avoid having a physiological effect. As Hennessey continues;
As
an art acupuncture is often practised in different styles. These
disparate styles affect different regions of the body: tapping done
on the surface of the skin, needling acupuncture points deeply, and
subcutaneous needling have their adherents. Practitioners often
combine treatment styles for what they believe will be an optimum
benefit. Creating an adequate sham seems to be a difficult illusion.
Without fully understanding the physiological mechanisms that
acupuncture influences, penetrating the surface or even engaging the
surface of the skin can have effects (2012: 7).
In
the end, even studies that show exceptional results in favour of
acupuncture are not particularly useful in informing the practise of
TCM therapists who are treating the public in private clinics. A good
acupuncturist will always perform a differential diagnosis of a
patient, taking into account their personal history and constellation
of signs and symptoms, make a diagnosis, form a treatment principle,
and then select points based on that information, and then use
techniques they deem to be the most clinically effective for the
case. It will never be the case that an experienced acupuncturist
will just use some protocol dreamed up as globally applicable in the
most recent positive study published, and apply it verbatim.
In
future, research should be conducted in one of the following ways;
Head to head trials comparing acupuncture to some other intervention,
where you have two groups of participants. An acupuncture only group
and a medication group. The acupuncture group would either be bound
by more rigorous inclusion/exclusion criteria, i.e. only liver qi
stagnation pattern subjects are included, and they must also have the
same underlying patterns of disharmony. This would be difficult since
it would take a long time to get the numbers needed to treat if you
only include patients with liver qi stagnation depression as the main
complaint, with liver fire harassing the heart style insomnia, and
spleen qi deficiency as an underlying pattern. A more logical way to
go about head to head studies to test the efficacy of acupuncture in
treating depression, is to actually treat the patients in the same
way they would be treated by an acupuncturist in a private clinic. A
patient comes in with a main complaint of depression, the treating
acupuncturist performs a full differential diagnosis, forms a
treatment principle and point prescription, and the patient is then
treated over the course of the trial, with variations to their
treatment at the discretion of the practitioner, in the same way it
would be in private practise. This is the only way to study weather
or not acupuncture is effective as a treatment for any condition. You
cannot study how a fish breathes underwater, if you put it in a tank
filled with air. You cannot evaluate acupuncture if you do not study
it in the context in which it is actually performed in the real
world. MacPherson et al. goes some way toward achieving this. In
their study outline of a proposed RCT, they describe a three arm
approach where acupuncture combined with usual care (medication), is
compared to counselling combined with usual care, and a third arm, of
participants who receive usual care alone. In this proposal for
research they intend to have registered acupuncturists with a minimum
of 3 years experience after registration, perform a TCM differential
diagnosis, and treat their patients accordingly (2012: 3). My only
contention with this study proposal is that the acupuncture group is
also receiving medication, which in the end restricts the amount of
valuable data available to assess acupuncture as a stand-alone
therapy against usual care. I do feel that this approach, in terms of
differential diagnosis, and individualised treatment, is a step in
the right direction for acupuncture research. Unfortunately, the
outcomes of this proposed trial have not yet been published.
Conclusion
To
conclude, this essay has evaluated key research on the treatment of
depression with acupuncture. I have taken into consideration both the
outcomes of the research reviewed, and the methodological quality of
the research. I have drawn attention to the marked contrast in
treatment outcomes between practitioners in private practise, and the
results obtained in clinical trials, and posited a theoretical basis
for this discrepancy, based on the inadequacy of contemporary
research methods for evaluating the efficacy of acupuncture as a
stand-alone therapy. I believe this conclusion to be equally valid
within the field of depression research, and the methods employed in
studying acupuncture as an intervention for a whole spectrum of both
psychological and physiological disorders. I believe that the obvious
pitfalls inherent in sham and placebo acupuncture will, in the near
future impact on the way acupuncture research is performed, and the
idea of RCT being the gold standard of scientific research will
inevitably change. This should result in more accurate and positive
outcomes for researchers, acupuncturists, and most importantly our
patients who come to us for treatment.
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Footnotes
1
The hypothalamic-pituitary-adrenal axis (HPA axis) is a complex set
of direct influences and feedback
interactions
among the hypothalamus,
the pituitary
gland,
and the adrenal
glands.
The interactions between these organs comprise the HPA axis, a major
part of the neuroendocrine
system that
controls reactions to stress
and
modulates many body processes, including the immune
system,
sexuality, mood and emotions, digestion
and
energy storage and expenditure (Mitrovic 2013: 465-85).
2
Dexamethasone, is a corticosteroid. It is similar to a natural
hormone produced by your adrenal glands. It is often used as a
replacement for this chemical when it is not produced in sufficient
quantities naturally. It reduces inflammation and treats certain
forms of arthritis; blood, skin, thyroid, kidney, eye, and
intestinal conditions as well as severe allergies and asthma. It is
also used to treat certain types of cancer (MedlinePlus 2013).
3
Immunosenescence
refers to the gradual deterioration of the immune
system brought
on by natural
age advancement.
It involves both the host’s capacity to respond to infections and
the development of long-term immune memory.
It
is thought to be a major contributor to the increased frequency of
morbidity and mortality among the elderly (Aw
et al. 2007: 435-446).
