Integration of Scientific Research and Chinese Medicine to treat Depression
Although acupuncture has been practiced for over 3000 years (Ulett 1992), the Western psychological and psychiatric scientific community has produced little empirical research on the efficacy of acupuncture. With the notable exception of acupuncture as a treatment for substance abuse and dependence (for reviews see Brewington et al 1994, McLellan et al 1993), there are very few well-controlled empirical studies of the efficacy of acupuncture for psychiatric disorders. The need for empirical trials is underscored by recent surveys documenting the popularity of alternative treatments for psychiatric and emotional disorders (Cassidy 1998, Eisenberg et al 1993, 1998).
This category is written in the hope of articulating how the traditional principles on which acupuncture is based can be applied to the treatment of psychiatric problems. It is written for clinical practitioners of acupuncture, for researchers, and for other healthcare providers interested in learning about the potential use of acupuncture in the area of mental health. This category is designed to provide a standardized frame-work for the assessment of depressive symptoms from the perspective of Chinese Medicine (CM) and a manualized approach to devising treatment plans that are individually tailored to address each individual’s constellation of signs and symptoms. It may be helpful to clarify that throughout this text the term standardization is used when referring to the standardization of the methodology employed in assessment and treatment design — in this case primarily the eight guiding criteria — to emphasize the selection of a specific framework. It should be differentiated-ferentiated from the current trend towards standardizing the practice of Chinese Medicine to reflect exclusively the traditional (TCM) model (Fruehauf 1999). The approach presented in this categroy is not intended to serve as the sole and definitive approach to the clinical treatment of depression with acupuncture. The field of Chinese Medicine continues to grow precisely because of the rich diversity of clinical approaches that characterize the profession. It is hoped that this category can serve as a model and offer inspiration for other acupuncture traditions; the advancement of our profession will depend on making it amenable to scientific inquiry, which has become the ‘gold standard’ for evaluating treatments and making policy decisions.
It is intended that this manual will not only facilitate research, but also open the opportunity for acupuncture practitioners to implement a manualized treatment approach in their own practice. The benefits of using such a manualized approach are many, but include: (1) greater systematic attention to detail, (2) the opportunity to implement an experimentally tested protocol in routine clinical practice, and (3) the opportunity to gather data on the effectiveness of a researched approach in the real world setting of clinical practice.
The approach taken in this manual follows from standard principles of Chinese Medicine, which are described in detail in standard texts such as The Web That Has No Weaver: Understanding Chinese Medicine (Kaptchuk 1983), The Practice of Chinese Medicine (Maciocia 1994), The Foundations of Chinese Medicine (Maciocia 1989), and A Compendium of Traditional Chinese Medicine Patterns and Treatment (Flaws & Finney 1996). The manual is designed for use with persons that meet Western criteria for major depression of less than 2 years’ duration, according to the diagnostic criteria of the Diagnostic and Statistical Manual, fourth edition (DSM-IV; American Psychiatric Association 1994).
ESSENTIAL FEATURES OF THE APPROACH
The features of the approach in this manual should be familiar to any practitioner trained in Chinese Medicine:
n An assumption that Western-defined depression is heterogeneous and may be characterized by one or more distinct patterns of disharmony, which may differ for different clients with depression.
- Differential diagnosis using signs and symptoms, client interview, taking of pulses, and an examination of the tongue, integrating five areas:
— eight principles
— qi, blood and body fluids
— viscera and bowels
— channels and network vessels
— five phases.
- Given a pattern of disharmony or combination of patterns identified through differential diagnosis, the development of specific treatment principles.
- The selection of points to address the treatment principles.
- Acute treatments delivered twice per week for 8 weeks, and once per week for 4 weeks.
- Maintenance and continuation treatments semimonthly and then monthly for the next year. •
- A goal of producing clinically meaningful change: improved balance rather than disharmony, remission as defined by DSM-IV criteria, and Hamilton Rating Scale for Depression (HRSD) score 6.
Moreover, this manual details assessment and treatment suitable for persons with DSM-IV-defined major depression of less than 2 years’ duration. The details of diagnosing major depression are covered in the next post. It is not necessarily the case that the framework and techniques in this manual are not useful, at least in part, for people who do not meet the restricted criteria for major depression, but the effectiveness of this treatment for conditions other than narrowly defined major depression has not been investigated systematically. More ovei although the approach has been tested with women, it is currently being tested with men. In addition, the approach remains untested with clients with comorbid disorders, dysthymia, and chronic depression. Finally, although it is the authors’ view that acupuncture can be fruit-fully combined with psychotherapy, this manual covers the use of acupuncture as the exclusive treatment, without adjunct treatments such as psychotherapy, pharmacotherapy, or herbal interventions.
A COMMENT ON THE INTEGRATION OF SCIENTIFIC RESEARCH AND CHINESE MEDICINE
This category was written, with the aim of promoting sound scientific research on acupuncture and depression, while still providing flexibility and individualization in assessment and treatment planning — a necessary feature of Chinese Medicine. The theoretical paradigms that underlie acupuncture are very different from the Western medical models. Therefore, proper research studies in this field must incorpor-ate an energetic diagnosis based on the principles of Chinese Medicine (CM) in order to identify treatment protocols correctly, rather than rely solely on Western diagnostic systems (Bensoussan 1990).
The utilization of a manualized treatment approach in clinical trials involving acupuncture provides the essential flexibility necessary to deliver individualized treatment, while conforming to the standardization fundamental to conducting sound research. The use of a treatment manual promotes the systematic articulation of the chosen framework (in this case primarily the eight principles), thus providing replicability and systematization while allowing for individualized treatment. Additionally, a manualized treatment approach increases the quality and consistency of the treatment by standardizing the technical aspects, providing a precise framework for training and supervision, enabling the evaluation of practitioner competence and conformity, and increas-ing the ability to identify the most essential therapeutic aspects of the approach. A treatment manual should not aim at limiting treatment options within a narrowly defined protocol, but rather it should provide the freedom to identify a variety of treatment possibilities within a sound conceptual framework.
According to Chinese Medicine, any piece of information (symptom or sign) gathered from the client can be interpreted only in relation to other symptoms and signs. The integration and consideration of all significant variables that relate to the process of diagnosis and treatment is paramount in Chinese Medicine. Rather than eliminate variables in order to control the treatment outcome, Chinese Medicine seeks to integrate all significant variables, in order to create the most effective treatment. A certain flexibility is needed to assess accurately the efficacy of acupuncture, precisely because the theory of acupuncture is structured around the integration of data. Nevertheless, some standardization of treatment is necessary for the purposes of replication in research and clinical practice (Bensoussan 1990).
In other words, individuals who share a Western diagnosis (e.g. depression) will be characterized by a variety of CM-based patterns of disharmony which, in turn, dictate particular treatments to address these patterns of disharmony. Treatments, therefore, must be tailored to each individual’s symptom picture; a ‘standard’ treatment must not be uniformly administered to all individuals who share a Western diagnosis. This manual describes the framework and procedures by which acupuncturists may reliably arrive at individualized diagnoses and treatment plans. In pilot work designed specifically to assess how well individuals could agree using this framework and these proce-dures, five women with major depression were seen independently by two acupuncturists within a 3-day period. Overall agreement was quite high, as indicated by an intraclass correlation coefficient1 of 0.78, summarizing their composite agreement. This result suggests that practitioners can agree on which pattern(s) of disharmony char-acterize any given individual’s depression, and agree on the treatment that should ensue.
Aside from our pilot study (Allen et al 1998), which is detailed in a future post, the only studies of acupuncture as a treatment for depression or depression-like syndromes have been published in China (Chengying 1992, Han 1986) and in Eastern Europe and the former Soviet Union (Cherkezova & Toteva 1991, Frydrychowski et al 1984, Polyakov & Dudaeva 1990, Polyakov 1987, 1988). It is difficult to evaluate these studies fully, because the diagnostic criteria used differ from those of the DSM-IV, and because most of these studies have not been translated into English (other than the abstracts). Collectively, however, these studies suggest that acupuncture may be effective in the treatment of depression and depressive symptoms, in some cases as effective as tricyclic antidepressant medication. The following review summarizes these studies, with a focus on the range of depressive symptoms for which acupuncture may and may not be effective.
Polyakov (1988) treated 167 depressed patients with acupuncture. Acupuncture reduced the principal symptoms of depression and also lessened the severity and prominence of supplementary symptoms. The best results from acupuncture were obtained in patients with melancholic depression; poor results were obtained in patients with anxious and apathetic depressions. Acupuncture was almost as effective as antidepressants in cyclothymic depressions and was notably inferior to tricyclic antidepressants in patients with psychotic features. Moreover, Polyakov (1988) reported that follow-up studies over 1-2 years indicated that adequate maintenance therapy produces results comparable to drug therapy, although inadequate information was provided to evaluate this claim. In this study, acupuncture was carried out using a standardized method of treatment that consisted of five acupuncture points located in the traditional meridians (St 36, P S, P 6, Lu 7, and LI 4) plus three ear acupuncture points (AT affect, AT Shenmen, and AT Zero). From the perspective of pattern differential diagnosis (the assessment method of Chinese Medicine), the finding of poor treatment response in anxious and apathetic depressions is not surprising, because this set of points does not specifically address the features present during anxious or apathetic depressions. This highlights the importance of considering individual differences in symptom presentation and tailoring points accordingly, as detailed in this manual.
Other studies provide only abstracts in English. Chengying (1992) used points on the Du channel (which runs along the spine) to treat a melange of psychiatric disorders including anxiety, depression, hypochondria, neurasthenia, obsessive—compulsive disorder, aphasia, alexia, and hysterical paralysis. A total of 115 patients with a course of disease from 2 months to 8 years were treated with points selected from the Du channel. Points were selected by pressing the points one by one, observing and comparing sensitivity to the points, and choosing to needle the 1-2 points with the maximum response. Of the 115 patients, 61 experienced complete disappearance of psychoneurotic and somatic symptoms and no recurrence at 6-month follow-up, 31 experienced a significant improvement, and 23 had no significant improvement after treatment. Although Chenying (1992) studied a heterogeneous group, the comparability of the diagnoses neurasthenia and major depression was noted by Chang (1984). Commenting on the observations of Dunner & Dunner (1983), Chang indicated that almost 50% of psychiatric outpatients in China are diagnosed with neurasthenia, and that many of these neurasthenics would be diagnosed by the DSM with major depression. Moreover, Chang (1984) noted that antidepressants were as effective with cases of neurasthenia diagnosed by Chinese psychiatrists as with cases of DSM-defined depression.
A further 103 patients with neurasthenia (course of disease from 3 months to 20 years, average of 4.5 years) were observed clinically at the Academy of Traditional Chinese Medicine (Suobin 1991). Principal points Du 14, Du 13, GB 20, the first line on the Bladder channel, bilateral to the spine and the Huatuo paravertebral points (M BW 35 (Jiaji); O’Connor & Bensky 1981) were used, along with other points chosen according to symptoms. Following treatment 45 patients were relieved of all their symptoms and were considered clinically cured, 29 experienced an improvement of the main symptoms but some secondary symptoms remained, 21 experienced a noticeable improvement, and eight had no improvement at all.
Another Chinese study, by Luo, Jia, and Zhan of the Institute of Mental Health, Beijing Medical College, examined electro acupuncture and amitriptyline treatment of DSM-III-defined major depression. This study, summarized by Han (1986), found comparable decreases in HRSD scores as a function of electro acupuncture and amitriptyline treatments over a 5-week interval: mean ± SD HRSD scores dropped from 28.5 ± 1.2 to 12.8 ± 2.0 for patients receiving acupuncture, and from 29.4 ± 1.4 to 14.2 ± 1.9 for those receiving amitriptyline. Moreover, fewer side effects were reported for patients receiving electroacupuncture. Unfortunately, this study used only two points (Du 20 and Yintang), and it is unclear whether standard needling, as opposed to electroacupuncture, would provide compara-ble results, although some (Ulett 1992) claim that the effect of acupuncture is due entirely to the frequency of stimulation rather than to the specific points selected. Another Chinese study (Hechun 1988; summarized by Brewington et al 1994) also found comparable decreases in depressive symptoms in patients having electroacupunc-ture and those receiving amitriptyline. Finally, acupuncture also appears to diminish depressive symptoms in the context of opiate detoxification (Cherkezova & Toteva 1991, Newmeyer et al 1984).
Although far from definitive, taken together these studies suggest that it is possible to obtain favorable results using acupuncture to treat mood-related symptoms, including depression. These findings encouraged us to undertake a pilot study to examine the efficacy of acupuncture as a treatment for depression.