Acupuncture for Treatment of Depression
Acupuncture for Treatment of Depression
January 2001; Volume 4; 5-8
By Barak Gaster, MD and Judith Balk, MD, FACOG
Getting stuck by needles does not sound very appealing to most people. However, acupuncture—the insertion of fine needles into specific points on the body—has grown quickly into one of the most popular forms of alternative medicine in the United States.1 Acupuncture now is used commonly to treat conditions as diverse as back pain, nausea, cocaine addiction, headache, and asthma.2
Depression is a common debilitating condition for which conventional medical therapies often fail or cause unpleasant side effects. A safe, well-tolerated treatment, such as acupuncture, thus would have tremendous therapeutic potential if it were effective. A literature review reveals only a scant amount of evidence, however, that acupuncture is effective for depression. Although the evidence may warrant further study, it is not enough to recommend acupuncture for this indication.
Background
Acupuncture first originated as part of traditional Chinese medicine more than 2,000 years ago. It is a complex discipline that is based on the concept of Qi (pronounced "chee"), a vital life force or energy that circulates through the body along channels called meridians.3 By inserting needles at acupuncture points located along the meridians, acupuncturists believe that they alter the flow of Qi, thereby restoring balance and health to a patient’s body.
A traditional acupuncture session begins with a detailed history, followed by an examination that includes observations of the shape and surface of the tongue and the strength and rhythm of the pulse.3 The acupuncturist uses this information to select between four and 10 points to insert the solid acupuncture needles, needles that usually are left in place for five to 30 minutes. The needles then are stimulated by manual twirling or by the application of heat or a small electrical current.3 The needles are so thin that, contrary to many Westerners’ fears, the process generally is painless.
Mechanism of Action
Various research programs have attempted to explain the efficacy of acupuncture from within the paradigm of Western science. Although there is some evidence that the stimulation of acupuncture points might affect the release of endogenous opioids or the uptake of neurotransmitters such as serotonin,4 it is not known whether acupuncture works via this mechanism for depression. Acupuncture is, however, one method of accelerating the synthesis and release of serotonin and norepinephrine in the central nervous system. Acupuncture also releases opioid peptides and gamma-aminobutyric acid, both of which may be related to depression and mania.5 The regulation of neurotransmitters may be influenced by acupuncture in a way that leads to homeostasis.6
Clinical Trials
Computerized literature searches of the MEDLINE, EMBASE, and Cochrane databases using the key words "acupuncture" and "depression" yielded 59 English-language citations. Three of these were trials testing the efficacy of acupuncture for the treatment of depression. One was an observational study without a control group.7 The other two were randomized, non-blinded, non-placebo-controlled trials comparing electroacu- puncture (EA) to amitriptyline (TCA).8,9
All three trials reported statistically significant improvements in depression scores in patients treated with acupuncture. However, the clinical significance of these findings is uncertain given the lack of placebo controls, since 1) depression naturally improves with time and 2) the placebo effect is known to be especially powerful in trials of antidepressants.10
In the first trial, patients with anxiety and depression were studied using a single-blind design.7 Patients taking antidepressants were excluded. Post-acupuncture scores for both depression and anxiety normalized in most of the patients at the one-month follow-up assessment.
The two trials that compared acupuncture to TCA showed no significant difference between the two groups,8,9 but the sample sizes were not large enough to exclude a clinically significant difference between the two groups.
A fourth non-randomized study compared 20 depressed patients treated with acupuncture with 21 controls treated with TCA.11 Hamilton Depression Scale was evaluated in all patients, and EEG was performed only in the acupuncture group. No difference occurred between groups for treatment effectiveness. Anxiety somatization was significantly more improved in the acupuncture group compared to the control group. EEG at the end of the acupuncture course showed significant changes from baseline and during the course of treatment, including decreased power of slow wave delta and increased fast wave alpha. Typically, depression is associated with the opposite findings; thus, treatment success with acupuncture may be related to changes in brain electrical activity.
EA has been compared with electroconvulsive therapy (ECT) for the treatment of depressive psychoses, including bipolar disease and schizoaffective disorder.12
Randomized, prospective, controlled trials of acupuncture for depression are rare. One such trial evaluated EA vs. TCA in 241 patients with "depressive psychosis."9 To be included, patients needed scores greater than 20 on the Hamilton Depressive Rating Scale. The acupuncture group received a daily placebo capsule and acupuncture for 60 min/d. The TCA group received daily TCA, with an average of 161 mg/d.
Both groups significantly lowered their Hamilton Depression Scores from baseline; no differences occurred between the groups. Recurrence rates also were similar between the two groups, even though the majority of patients in both groups were taking antidepressant therapy.
Subgroup analysis revealed that for most syndromes the two modalities were equal, but acupuncture was superior in two groups: anxiety somatic syndrome and cognitive disorder syndrome. Side effects were higher for the TCA group compared to the acupuncture group. Findings are similar to an earlier study published by the same lead author.8 This study is limited by a non-masked design, a short treatment time, and a wide group of disorders being treated.
Recently, a group of German investigators conducted a single-blind controlled study of acupuncture for in-patients with major depression.13 All patients were on antidepressant therapy. Patients then were randomized to true acupuncture, sham acupuncture, or a control group. The sham group received superficial needling at non-acupuncture points. Acupuncture was applied three times per week for four weeks.
Both forms of acupuncture improved depression more than the (no-acupuncture) control group, but there were no differences between true and sham acupuncture.
The authors suggest several possibilities to explain the findings. One factor is that perhaps the location of the needles is unimportant, and hence sham needling would be effective. Another possibility is that the effect seen might be the result of additional attention that the acupuncture groups received, or that the acupuncturists treated the groups differently, favoring the sham group. An attention control group would help sort out this issue.
Luo et al studied inpatient depression in a randomized, double-blind, placebo-controlled study with 29 inpatients.14 Patients received either EA plus placebo, TCA, or EA plus TCA for six weeks. Therapeutic efficacy and side effects were evaluated. Based on the results of this small study, the same authors conducted a larger, multicenter study. Patients were randomized to one of two groups: EA plus placebo or TCA. No difference existed between groups for therapeutic efficacy overall. However, acupuncture was more effective for anxiety somatization and cognitive process disturbance of depressed patients. Side effects of acupuncture were significantly fewer than those occurring with TCA. Although this study is controlled, a placebo effect for acupuncture still might exist.
Treatment Protocols
In most of the depression trials, acupuncture was administered daily for a period of six weeks. A typical course of acupuncture in the West, however, consists generally of weekly sessions lasting from six to 12 weeks, followed by maintenance therapy occurring once every one to six months, as needed.3
Anecdotally, several Western investigators note that their experience is limited to weekly office treatments for less severe depression, and that this less intense schedule has permitted a decrease, and in some cases, an elimination in the need for antidepressant medication.15 One case study used twice weekly treatment with good success.16 Acupuncture points used, types of stimulation, frequency of acupuncture sessions, and length of course of acupuncture for six clinical studies are shown in Table 1.
| Table 1-Clinical trials of acupuncture for depression | ||||
| Reference | Acupuncture Points | Stimulation | Frequency | Length of Treatment |
| Jacob17 | GV-20, Yintang, GB-38, LR-3, LR-5, Ear: Symp, Liver |
electrical | 2 d/wk | 40 treatments |
| Roschke14 | BL-15, 17, 18, HT-7, P-6, ST-40, SP-5, SP-6, LU-1 |
manual | 3 d/wk | 4 wks |
| Yang11 | GV-24, 20, 14, 12, CV17, 14, GB-20, P-6 | electrical | 6 d/wk | 6 wks |
| Luo9 | GV-20, Yintang | electrical | daily | 6 wks |
| Shuaib12 | "below ridges of pinnae of both ears" | electrical | variable | variable |
| Luo15 | GV-20, Yintang | electrical | 6 d/wk | 6 wks |
Safety and Adverse Effects
In the right hands, acupuncture is safe with an extremely low risk of serious complications. In a prospective study of more than 55,000 acupuncture treatments given in a college of medically trained acupuncturists, only 63 minor adverse events, including transient hypotension, bruising, and dermatitis, were recorded.17 No major events such as spinal injury, pneumothorax, or tamponade were recorded, although case reports of such complications appear each year in the literature; pneumothorax is the most frequently reported of these.18-20 Of course, a risk to the patient also exists if acupuncture is ineffective and is used in place of effective antidepressant therapies.
Acupuncture should be avoided in patients with valvular heart disease,21 although the rate of transient bacteremia from acupuncture needling is likely to be very low. Because of bleeding risk, acupuncture should not be used in patients who have bleeding disorders or who are taking anticoagulant drugs.
Conclusion
Although depression sometimes is included on lists of conditions for which acupuncture may be helpful, no randomized controlled trials have compared acupuncture to placebo for the treatment of depression. Although a limited number of trials suggest that patients’ depression scores may improve with the use of daily acupuncture, the clinical implications of these findings are uncertain given the typical weekly frequency of acupuncture in the West. At this time, data are too limited to recommend acupuncture as a first-line approach for depression.
Recommendation
Until more rigorous trials demonstrate better efficacy, acupuncture should not be recommended routinely for the treatment of depression. Acupuncture, however, has few side effects and contraindications. If a patient is unresponsive to or intolerant of standard approaches, and is interested in a non-Western approach, acupuncture may be tried. Because serious adverse events can occur, though rarely, patients who try acupuncture should be advised to seek licensed, experienced practitioners.
Dr. Gaster is Assistant Professor, Department of Medicine at the University of Washington in Seattle; Dr. Balk is Assistant Professor, Department of Obstetrics/Gynecology at the University of Pittsburgh.
References
1. Eisenberg DM, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575.
2. Pearl D, Schrollinger E. Acupuncture: Its use in medicine. West J Med 1999;171:176-180.
3. Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ 1999;319:973-976.
4. NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518-1524.
5. Han JS. Electroacupuncture: An alternative to antidepressants for treating affective disease? Int J Neurosci 1986;29:79-92.
6. Riederer P, et al. Manipulation of neurotransmitters by acupuncture. J Neural Transm 1975;37:81-94.
7. Tao D. Research on the reduction of anxiety and depression with acupuncture. Am J Acupunct 1993; 21:327-329.
8. Luo HC, et al. Electro-acupuncture vs. amitriptyline in the treatment of depressive states. J Tradit Chin Med 1985;5:3-8.
9. Luo HC, et al. Electroacupuncture in the treatment of depressive psychosis: A controlled prospective randomized trial using electro-acupuncture and amitriptyline in 241 patients. Int J Clin Acupuncture 1990;1:7-13.
10. Linde K, Mulrow CD. St. John’s wort for depression (Cochrane Review). In: The Cochrane Library. Oxford: Update Software; Issue 3: 2000.
11. Yang X, et al. Clinical observation on needling extra channel points in treating mental depression. J Tradit Chin Med 1994;14:14-18.
12. Kurland H. ECT and Acu-EST in the treatment of depression. Am J Chin Med 1976;4:289-292.
13. Roschke J, et al. The benefit from whole body acupuncture in major depression. J Affect Disord 2000;57: 73-81.
14. Luo H, et al. Clinical research on the therapeutic effect of the electro-acupuncture treatment in patients with depression. Psychiatry Clin Neurosci 1998;52(suppl): S338-S340.
15. Ulett GA, et al. Electroacupuncture: Mechanisms and clinical application. Biol Psychiatry 1998;44:129-138.
16. Jacob W. A case of severe chronic depression treated with acupuncture. Medical Acupunct 1990;2.
17. Yamashita H, et al. Adverse events related to acupuncture. JAMA 1998;280:1563-1564.
18. Ernst E, White A. Life-threatening adverse reactions after acupuncture? A systematic review. Pain 1997;71:123-126.
19. Peuker ET, et al. Traumatic complications of acupuncture. Therapists need to know human anatomy. Arch Fam Med 1999;8:553-558.
20. Kirchgatterer A, et al. Cardiac tamponade following acupuncture. Chest 2000;117:1510-1511.
21. Ernst E, White A. Acupuncture: Safety first. BMJ 1997;314:1362.
January 2001; Volume 4; 5-8
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