Future Directions in Depression Treatment with Acupuncture
We have outlined a manualized approach to the treatment of depression, one that is based on the individual’s unique experience of depression and that aims to address each particular constellation of signs and symptoms based on pattern differentiation according to Chinese Medicine.
Although the protocol outlined in this manual has been tested in a small sample of women with major depression, much work remains to be done. A larger-scale National Institutes of Health (NIH)-funded clin-ical trial including men as well as women is currently underway. It has yet to be determined, however, whether acupuncture may be effective in treating chronic or severe depression, or whether it may be useful in treating depression with comorbid disorders such as substance abuse, eating disorders, and anxiety. It is not known whether acupuncture may treat the depressive phase of bipolar disorder, or whether it may be helpful in treating chronic depression or dysthymia.
The long-term prognosis of responders is unknown, and the role of acupuncture as a maintenance treatment needs to be further explored. In acupuncture, after completing a course of treatment, it is generally recommended that people receive maintenance treatments. The fre-quency and rate of treatments after the acute phase varies, depending on the nature of the condition being treated, the constitutional predis-position of the individual, and their lifestyle choices. As a minimum, acupuncturists would recommend that people receive an acupuncture seasonal `tune-up’ every time the season changes, or approximately four times a year. The concepts of treatment maintenance and continuation are at the core of the practice of Chinese Medicine.
Additionally, it would be worth investigating ways in which acupuncture can assist in facilitating a full recovery from depression. Many individuals who receive treatment for depression are left with a range of residual symptoms. For such people, it would be worth investigating:
n whether the effects of acupuncture alone may be further enhanced by applying it within the context of Chinese Medicine as a complete system — when combined with Chinese herbal medicine and lifestyle and dietary changes
n whether acupuncture may enhance the effect of antidepressants, and whether it may help to counteract some of the adverse side-effects of medications, or reduce the dose of medication required
n whether nonresponders to medication may respond better to acupuncture alone or in combination with medication
n whether combining acupuncture with psychotherapy would enhance the therapeutic effect of either treatment on its own
n whether there may be an enhancement of the therapeutic effect achieved by combining medication, psychotherapy, and acupuncture.
Finally, there are certain populations for which new treatment approaches may be especially welcome. In particular, we will review the need for treatment in three populations for which the use of med-ication may be difficult: the elderly, women during pregnancy and postpartum, and adolescents.
DEPRESSION IN OLDER ADULTS
Among older adults the prevalence of depression is comparable to that in the general population, but the economic and personal costs may be greater than for younger individuals with depression. Recent commu-nity-based (Penninx et al 1998) and primary care clinic-based (Unutzer et al 1997) studies suggest that 10-14% of respondents over age 65 or 70 years suffer from clinically significant depression. Moreover, older individuals with depression incur, on average, almost 50% more healthcare costs in a year’s time than do age-matched nondepressed individuals (Unutzer et al 1997), and experience a markedly greater decline in physical capabilities over a 4-year period (Penninx et al 1998). The findings of a recent study suggest that symptoms of depression may function as precursors of future fractures (Whooley et al 1999) as well as diseases diagnosed in the future, and represent a health risk factor comparable in severity to smoking (Shugarman et al 1999). Furthermore, depressive symptomatology may portend cogni-tive decline in community-dwelling elderly among those with average cognitive function (but not those with high function; Bassuk et al 1998). Finally, suicide rates increase with age and are highest among white men aged 65 years and older (Centers for Disease Control (CDC) 2000a). For every 100 000 people aged 65 years and older, 16.8 committed suicide (Hoyert et al 1999), with men accounting for 83% (CDC 2000a). From 1980 to 1997, the largest relative increases in suicide rates occurred among those aged 80-84 years (CDC 2000a).
For geriatric depression, alternative treatments are additionally important because some traditional interventions may be contraindi-cated, or not considered acceptable, in the older cohort. Traditional tri-cyclic antidepressant medications are often not used in the older adults, as they may cause orthostatic hypotension (leading to increased falls and fractures), or because geriatric patients are particularly sensitive to the anticholinergic, cardiovascular, and sedative side effects (NIH Consensus Panel 1992). With respect to newer antidepressant agents, there is a paucity of data on the use of these antidepressants in older patients (Flint 1997). Selective serotonin reuptake inhibitors (SSRIs), which generally produce fewer and more tolerable side effects, are not without problems for use in older adults. SSRIs may induce postural instability in older people, increasing the risk of falls (Laghrissi-Thode et al 1995), and virtually all cases of SSRI-induced hyponatremia have occurred in older people (Liu et al 1996). Whereas in healthy volun-teers SSRIs produce no significant cardiac effects, their use in patients with cardiac disease has not been well studied (Sheline et al 1997). Finally, the SSRIs inhibit enzymes involved in the metabolism of a large number of drugs; the result would be that the level of a variety of med-ications in the blood could be increased when taking these SSRIs (Newhouse 1996), particularly in older adults who, on average, take more medications than their younger counterparts. Acupuncture thus has the potential to offer relief from depression in older adults without the possible risks associated with medication.
DEPRESSION DURING PREGNANCY
Depression is common during pregnancy, with a higher prevalence for depressive symptoms compared with rates of major depressive disor-der. Estimated rates for depressive symptoms range between 28% and 34% (O’Hara et al 1984, Rees & Lutkins 1971) with even higher rates (47%) among women of low socioeconomic status (Seguin et al 1995). Despite this documentation of high prevalence, we know rela-tively little about the onset and course of depression during preg-nancy. Kitamura and colleagues (1993) reported onset during pregnancy in about 15% of the depressed pregnant Japanese women they studied. Others (Ballinger 1982, Gotlib et al 1989, 1991) reported that both the incidence and severity of depression during pregnancy increased from the first to the third trimester. Some of these studies also reported that approximately one-third of women who were depressed during pregnancy continued to be depressed after delivery and that half of the women who had postpartum depression were depressed during pregnancy. Moreover, among women who were not clinically depressed during pregnancy, women who became depressed during the postpartum period (4.2%) experienced more depressive symptoms during pregnancy than those who remained nondepressed during the postpartum period (Gotlib et al 1991).
Depression during pregnancy has additional deleterious effects in terms of the wellbeing of the fetus and of the mother following deliv-ery. For example, Orr & Miller (1995) found that among African American women the incidence of preterm delivery was greater in those with more depressive symptoms during pregnancy than in women with few depressive symptoms. Steer and colleagues (1992) reported an increased risk for delivering infants of low birthweight among inner-city women with more depression symptoms compared with those with fewer depression symptoms (20% versus 8%). Similarly they found that, in the same sample, the more depressed women had a greater incidence of preterm delivery (25% versus 8%) and a higher incidence of infants who were smaller than gestational age (15% versus 6%). In terms of the mother’s wellbeing, depression during pregnancy is a significant risk factor for postpartum depression (Cutrona 1984, Lum 1990, O’Hara et al 1982, 1984, Pfost et al 1990, Whiffen 1988). Studies in the past two decades have reported that between one-quarter and one-third of women who were depressed during pregnancy experienced depression during the postpartum period as well (Gotlib et al 1989, Watson et al 1984), and maternal postnatal depression has been linked to disturbance in behavior and cognitive development of the infant (Cogill et al 1986, Murray 1992, Whiffen & Gotlib 1989, Wrate et al 1985, Zuckerman & Beardslee 1987). Moreover, maternal depression during the postpartum period can interfere with the normal bonding and attachment process, and compromise the mother’s ability to learn effective caretaking and par-enting skills (Stein et al 1991, Whiffen & Gotlib 1989, Williams & Carmichael 1985, Wrate et al 1985).
The treatment options available for depressed women during pregnancy are frequently limited. Although psychotherapy is a safe treatment option during pregnancy, it is not readily available in the Health Maintenance Organization (HMO) dominated market and may not be acceptable to all pregnant women. Pharmacological treatments are often not advised during pregnancy; clinical guidelines for the pharmacological treatment of depression during pregnancy recommend that the risks to the woman and fetus associated with no treatment be weighed carefully relative to the risks of treatment (American Psychiatric Association 1993, Coverdale et al 1996, Robert 1996). Physical and behavioral abnormalities have been linked to the use of antidepressant medications during pregnancy (e.g. Ramin et al 1992). Manufacturers of all antidepressants advise that they be avoided during pregnancy, and many women are reluctant to undergo phar-macological treatment for their depression. Consequently depressive symptoms during pregnancy are often tolerated by the patient and remain untreated. Acupuncture holds the potential to offer relief to women experiencing depression during pregnancy without the possi-ble risks associated with medication.
DEPRESSION IN ADOLESCENTS
The incidence of depression in adolescents is close to 20% (Lewinsohn et al 1999). Early onset of depression strongly increases the risk for recurrent depressive disorders during adulthood (Harrington et al 1990, Kovacs 1996, Pine et al 1998, Rao et al 1995), and because depression tends be a chronic and recurrent con-dition people who experience depression in their teens are likely to experience depression again. Additionally, suicide is the third leading cause of death among people aged 15-24 years (CDC 2000b) and the prevalence of teen suicide is on the increase (CDC 2000a).
A trend towards an earlier age of onset of depression has been observed throughout the twentieth century (Klerman 1990). Major depressive episode is by far the most prevalent affective disorder among adolescents (Lewinsohn et al 1998). Earlier onset of major depression has been associated with being female, with having lower parental education, with the presence of psychiatric comorbidity, and with a history of suicide attempt. In younger children, depression may manifest differently and therefore be missed by conventional diagnos-tic criteria (Oldenhinkel et al 1999). The rates of adolescent and child-hood depression may therefore be seen as conservative estimates (Costello et al 1996, Cooper & Gooyer 1993).
Although suicide attempts among adolescents almost always occur in the context of significant psychopathology (Andrews & Lewinsohn 1992), and the likelihood of suicide attempt increases greatly given the presence of multiple (comorbid) psychiatric disorders (Lewinsohn et al 1998), suicide attempts are still most highly associated with major depression, in conjunction with alcohol and drug use, disruptive behavioral disorders, and anxiety disorders (Lewinsohn et al 1999). Furthermore, the rate of suicide among adolescents is alarmingly high: in 1997 alone 11.4 of every 100,000 adolescents commited suicide and 13.3% of all deaths in this age group are from suicide (Hoyert et al 1999). Moreover, over the 17 years from 1980 to 1997, the rate of suicide increased among all adolescents, but most alarmingly among persons aged 10-14 years, increasing by 109% (CDC 2000a), although the last few years have shown little increase.
Based on the Youth Risk Behavior Survey (YRBS) conducted among high-school students by the Centers for Disease Control and Prevention (Kann et al 1998), in 1997 21% of adolescents aged 14-17 years seriously consid-ered suicide and 8% attempted suicide, with 3% of such attempts requiring medical attention; over 1000 young people successfully com-mitted suicide in the United States on that same year. The use of acupuncture in the treatment of depression among adolescents holds the potential not only to address current symptoms, but also to have a significant impact on the developmental trajectory of those who are at a critical juncture in life. Treating depression early in life, at this criti-cal developmental period, is important for several reasons. First, ado-lescence is a period in which people make important developmental choices, which may be seriously affected by depressive symptoms (Oldenhinkel et al 1999). Second, early onset of depressive disorder strongly increases the risk for recurrent depressive disorder during adulthood (e.g. Harrington et al 1990). Finally, depressive symptoms can lead to unfavorable consequences such as substance abuse and impairment in interpersonal relationships and global functioning (e.g. Birmaher et al 1996).