Putting a square peg into a round hole may be the best way to describe trying to fit research in acupuncture into the Western medical model for determining its effectiveness in treating physical ailments. So when it comes to evaluating acupuncture for the treatment of mental health problems the peg fits even less. Traditional Chinese Medicine (TCM) does not share the same perspectives on these mood conditions as Western medicine.
Acupuncture is the best-known aspect of traditional Chinese medicine (TCM) in the West. The term acupuncture, however, can be misleading, as it is understood by many to imply a coherent and uniform model of practice. Not only is there evidence of a wide range of treatment techniques and diagnostic assessment methods, but the conceptual frameworks underpinning acupuncture practice also show considerable variety, in both traditionally based and modern frameworks.
Essentially, the treatment involves the insertion of fine needles at specific points along supposed energy channels called meridians. This is designed to stimulate blocked or pathogenic energy. It is based on such Chinese concepts as qi (energy) and yin-yang (female-male) balance, both of which are alien to Western medicine.
Depression and anxiety are seen, from a TCM perspective, as both emotional/psychological and physiological in nature, resulting from imbalanced energy effecting physical and mental health. Acupuncture claims to be effective in preventing and relieving various health problems through the correction of imbalanced energy. It is a holistic approach that, it is claimed, gives patients a more optimistic assessment of their problems and has few side effects.
There are a number of conceptual problems with carrying out acupuncture research. Staebler et el (1994) describes how conventional medical research looks for a "constellation of symptoms" and tries to apply one diagnostic label and one standard treatment. Acupuncture, however, is based on the whole-person approach. It takes into consideration the constitution of the person as well as the present disposition, by paying attention to the continuously changing equilibrium of life energy due to external and internal factors such as trauma, diet, climate and social conditions.
In daily practice, an acupuncturist would design treatment according to the specific needs of the individual patient. Attempts are made to establish the causative factors, and every case of depression and anxiety has some variation requiring different strength and location of needling. This presents another challenge in experimental research: test-retest reliability can be problematic as different therapists use slightly different techniques that vary according to the idiosyncratic nature of the individual's condition.
There are further problems for researchers. The use of one diagnostic label and one standard treatment would seem to be inappropriate in most cases of depression and anxiety. There are issues to be addressed of whether conditions are assessed according to Western diagnosis or TCM diagnosis, and which model is used to measure outcomes. The researcher could use conventional Western medical indices or incorporate TCM specific measures such as pulse and tongue diagnosis.
Other restrictions on the availability of acupuncture research relate to the nature of the profession. Most acupuncturists in the U.K. work as private practitioners. There are presently no obligations for acupuncture colleges, professional associations or individual practitioners to do research. It is easy to see why acupuncturists with little spare time, no specific knowledge of research, no access to established research units, no career opportunities in research, no experience in raising the funds, little appreciation that research is necessary in the first place and no legal obligation to conduct it, have been slow to take up the challenge.
Studies of Acupuncture for Depression and Anxiety
Notwithstanding these difficulties, various types of research have been conducted to try and assess the efficacy of acupuncture in the treatment of depression and anxiety, and most suggest there is therapeutic benefit.
Qun (1993) used his clinical case reports of two young people displaying a range of psychological symptoms. Both were experiencing depression, anxiety, guilt-feelings, sleeplessness, and inability to eat. Both had been treated with chlorpromazine to little effect. At the end of acupuncture treatment, Qun reports that both were completely cured and had no recurrence in eight years of follow-up. The problem with clinical case reports is that they tend to be the view of one person, the therapist, and are not independently validated. Bias may be generated by the practitioner selecting cases where the greatest success was achieved or exaggerating the degree of success in the cases reported.
A number of clinical trials have also been conducted. Luo et al (1985) compared acupuncture with amitriptyline in the treatment of depressed patients. Patients were randomly assigned for one of the two treatments. The acupuncture group comprised 27 patients and the drug group 20 patients.
Immediately before and during the period of therapy, each patient was interviewed by two psychiatrists. After five weeks, both groups had experienced a significant decrease in depression, though the differences between the two groups were not significant. The drug group experienced a range of side effects such as dizziness, fatigue, palpitation, dry mouth and constipation. The acupuncture group did not experience any of these side effects, only some complaints of mild painful sensation at the point of stimulation. The study concluded that as acupuncture produced comparable anti-depressive effect with fewer side effects it had a significantly higher therapeutic benefit.
Dong (1993) carried out, in a Chinese hospital, a trial in which 68 people suffering chronic psychiatric problems were treated with acupuncture. Of this group, 11 were suffering from anxiety, 8 had depression and 49 had both anxiety and depression. Patients were excluded from the trial if they were taking mood-altering medication. Anxiety and depression rating scales were used before and after treatment. One month after acupuncture, a significant reduction in anxiety and depression was measured. Anxiety had decreased to a normal level in 70 percent of cases and depression to a normal level in 90 percent of cases.
Issues relating to the number and frequency of acupuncture sessions and overall duration of treatment have been explored by Yang et al (1994). They conducted clinical trials of acupuncture on people experiencing varying degrees of anxiety and depression. They identified an optimum number of treatments for most cases as twice weekly over a six-week period. This gives the treatment sufficient time to take effect and stabilise the condition.
Other methods, such as patients writing a diary, are also appropriate for research in this field as they allow people to describe moods and feelings in depth and in their own way over time without the constraints of standardised tick box questionnaires. Themes can also emerge from diaries that can help identify other factors, in addition to the treatment itself, which may benefit outcome such as the importance of the therapeutic relationship and belief in the effectiveness of the treatment. People can also be asked to record significant life events that occur during the research in order to control for their influence on the findings.
Conclusions
Any mental health research needs to carefully consider questions of how and by whom a successful outcome is defined, and whether improvement in mental health can be sustained long term beyond the initial post-treatment phase. It would be sensible then to re-assess people at, for example, six months after acupuncture treatment has concluded. There are many difficulties in evaluating a treatment from another culture, delivered outside of its own cultural context, and based on concepts generally unknown within Western medical thinking. Such difficulties are compounded when the focus is on mental health, itself a relative concept based on subjective value judgements and difficult to apply cross-culturally. Despite these challenges, the evidence does suggest that acupuncture has some therapeutic benefit without the risk of the unpleasant side effects often associated with anti-depressant medication.
References:
Dong, J.T. (1993) "Research on the Reduction of Anxiety and Depression with Acupuncture." American Journal of Acupuncture, Vol.21, No.4, pp.327-9
Luo, H.C., Jia, Y.K., and Zhan, L. (1985) "Electroacupuncture vs. Amitriptyline in the Treatment of Depressive States," Journal of Traditional Chinese Medicine, Vol. 5, pp3-8
Qun, Q. (1993) "Two Cases of Mental Disease Treated by Acupuncture," International Journal of Clinical Acupuncture, Vol. 4, No. 1, pp. 93-5
Staebler, F.E., Wheeler, J., Young, J., Diebschlag, F and Blackwell, R. (1994) "Why Research into Traditional Chinese Acupuncture has Proved Difficult. Strategies of the Council for Acupuncture in the U.K., to Overcome the Problem," Complementary Therapies in Medicine, Vol. 2, pp. 86-92
Yang, X., Liu, X., Luo, H. and Jia, Y. (1994) "Clinical Observation on Needling Extrachannel Points in Treating Mental Depression," Journal of Traditional Chinese Medicine, Vol. 14, No. 1, pp. 14-18
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