Depression in Chinese Medicine

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).