Because of the significant number of patients who not respond to or who cannot tolerate conventional treatments for depression, other options must be explored. The data presented here suggest that acupuncture deserves further research as an alternative option for the treatment of depression.
Benefits and Limitations of Adjunctive Treatment and Monotherapy
By Pavel Jalynytchev, Lic Ac and Valentina Jalynytchev, MD | 12 May 2009 Tuesday
Dr Pavel Jalynytchev is a licensed acupuncturist at South Natick Wellness Clinic in Natick, Mass. Dr Valentina Jalynytchev is at Newton-Wellesley Hospital in Newton, Mass. They report no conflicts to disclose regarding the subject matter.
Acupuncture is being integrated into Western medicine, particularly for treatment of pain, nausea, asthma, and neurological conditions.1 Although the exact mechanism of action for acupuncture is unknown, it is associated with an increase in the level of neurobiologically active substances, such as endorphins and enkephalins.2 There are also data indicating that acupuncture induces the release of norepinephrine, serotonin, and dopamine.3-5
ADVERSE EFFECTS
Acupuncture is well tolerated compared with tricyclic antidepressant medications.6-9Adverse effects are mild and transient and include tiredness, drowsiness, exacerbation of primary symptoms, and itching in the area of acupuncture.10Complications such as pneumothorax, infection, cardiac conditions, and spinal cord injury are extremely rare.10
AVAILABLE DATA
The number of studies of Western acupuncture in the treatment of depression and conditions associated with depression is limited.10 Even fewer reports provide objective data to support efficacy (eg, neurotransmitter) level change, imaging studies, and electroencephalographic alterations. Only 7 randomized comparative studies have been published, even though the first attempts to compare acupuncture with conventional treatments for depression began in the 1970s.
Kurland11 presented case reports of 3 females with severe mood disorders who were treated with electroconvulsive therapy (ECT) and electroacupuncture therapy (EAT). EAT is a form of acupuncture in which 1 or more pairs of needles are stimulated by applying small electrical currents. All 3 patients had severe depression and had not responded to multiple trials of different psychotropic medications and psychotherapies. ECT reduced depressive symptoms but was associated with profound memory loss, confusion, and disorientation. Acupuncture administered with EAT resulted in significant remission of depression and was better tolerated by all 3 patients. The authors emphasized that EAT should not be a substitute for antidepressant or antipsychotic medications or ECT. EAT alone is less effective than ECT.
Although the exact mechanism of action of ECT and EAT is still unknown, Chang12hypothesized that the antidepressant effects of both were associated with a change in activity of serotonin and norepinephrine. In addition, he stated that EAT “might be safer than ECT.”12
Later, Fink13 disagreed with Chang, pointing out that the therapeutic effect of ECT was related to seizure activity.
Acupuncture and antidepressants
In the early 1970s, H. L. Wen, a neurosurgeon from Hong Kong, learned that acupuncture may significantly reduce drug withdrawal symptoms. In 1977, Shuaib and Haq14 made one of the first attempts to evaluate the effectiveness of Wen’s technique of acupuncture on psychosomatic symptoms in patients with neuroses secondary to pharmacological treatment. Participants experienced a reduction in tension, restlessness, sadness, headache, cephalic paresthesia, and loss of appetite during the study. However, obsessional symptoms were unchanged. The authors viewed acupuncture as a safe and potentially effective method of treating depression.
Several studies have compared acupuncture with antidepressants (mainly tricyclics) in the treatment of depression. In a controlled trial, 20 patients were treated with acupuncture 6 times per week, and 21 patients were treated with 150 to 300 mg/d of amitriptyline (control group).15 Both treatments lasted 6 weeks. No significant difference in effect (P > .05) was registered; symptoms of depression improved in both groups. However, change in anxiety somatization was significant in the acupuncture group (P < .01) compared with the control group.
Luo and associates6 compared the effects of EAT and amitriptyline on patients with depression. Results showed that EAT had a more evident therapeutic effect on anxiety somatization and cognitive process disturbance than amitriptyline (P < .05). EAT also appeared to be more effective for reactive depression than amitriptyline. Adverse effects from EAT were significantly lower than from amitriptyline (P < .001). Biochemical tests showed a significant norepinephrine plasma level change after EAT, which suggests that the therapeutic effect of EAT was due to the modulation of norepinephrine metabolism. EAT had a preferable adverse-effect profile. In terms of efficacy of EAT in treatment of depression, results of this study are promising.
Both studies demonstrated comparable efficacy between acupuncture and amitriptyline. However, because they were conducted in China, where the therapeutic outcome of acupuncture is highly expected, the placebo effect cannot be ruled out.
No significant difference between acupuncture and fluoxetine was found in 2 trials that included patients with poststroke depression.7,16 Both studies indicated that the patients did not tolerate fluoxetine as well as acupuncture. These efficacy findings were supported by Mukaino and associates,17 who systematically reviewed randomized controlled trials and suggested that the therapeutic effect of EAT might not be significantly different from conventional antidepressants.
Roschke and colleagues8 conducted a single-blind, placebo-controlled study that tested two hypotheses: (1) the combination of acupuncture and antidepressant medications (mianserin, a tetracyclic antidepressant that is used in Europe) is more effective for depression than pharmacological treatment alone (dosage of 90 to 120 mg/d), and that (2) verum (traditional) acupuncture is more effective than sham acupuncture in the treatment of depression.
Results of the study showed that patients who received combined mianserin and acupuncture (verum or sham) improved more than patients who were treated with mianserin alone. No significant difference was detected between patients who received verum acupuncture and those who received sham acupuncture. These results suggest that acupuncture has an unspecific augmenting effect on traditional antidepressants.8
Acupuncture as a monotherapy
In a double-blind, placebo-controlled study designed to assess the efficacy of acupuncture as a monotherapy for depression, 38 women were randomly assigned to 1 of 3 groups and received treatment that lasted 8 weeks: (1) specific acupuncture for depressive symptoms (n = 12), (2) nonspecific acupuncture for general feelings of “disharmony” (n = 11), and (3) wait-list controls (n = 10).9 Patients and acupuncturists were blinded using valid but different acupuncture points. All acupuncturists expected that the treatment they provided would be effective for depression.
Symptoms were reduced significantly more in the specific group (P < .05) than in the nonspecific group. However, the difference between specific acupuncture and wait-list groups was marginal (P < .12). These findings might be explained by the small sample size of the study. The remission rate (64%) was comparable to that for conventional treatments of depression.
This study suggests that acupuncture can be an appropriate monotherapy for mild to moderate depression. However, the results of a similar, larger trial (N = 151) failed to support acupuncture as a monotherapy for depression.18
In another double-blind, placebo-controlled study, Eich and colleagues19 compared verum and placebo acupuncture applied to patients with minor depression (n = 43) and patients with generalized anxiety disorder (n = 13). Treatment consisted of 10 acupuncture sessions (verum or placebo). The verum acupuncture group (n = 28) showed significant clinical improvement (P < .05) and had a significantly higher response rate (60.7% vs 21.4%; P < .01) of decreased anxiety symptoms in patients with depression and generalized anxiety disorder.
Long-term effects
Despite continued psychopharmacological and/or psychotherapeutic treatment of depression, relapse rates are high. Gallagher and associates20 focused on the long-term prognosis for patients with depression who were successfully treated with acupuncture in the study by Allen and colleagues9 described previously. Seventeen of 26 patients had achieved full remission during the acute phase of that study.
In the follow-up phase, 26 participants were assessed using a Structured Clinical Interview for the DSM after 6 months of treatment. Four (24%) of the 17 women who achieved full remission after specific acupuncture experienced recurrence of depression within 6 months. Six of the 9 patients with partial remission (67%) also had a major depressive episode during the 6-month follow-up period.9
This study indicates that response rates and relapse rates with acupuncture are comparable to those with traditional treatments of depression. Smith and Hay21 also found no evidence that medications are better than acupuncture in helping patients achieve remission or in preventing relapse.
Acupuncture and depression in pregnancy
Manber and colleagues22 studied the therapeutic effect of acupuncture on pregnant women with depression. The results are particularly interesting. Sixty-one women were randomly assigned to 1 of 3 groups: (1) acupuncture, in which depressive symptoms were specifically addressed (SPEC) (n = 20); (2) valid controlled acupuncture, which was not specifically tailored for depression (NSPEC) (n = 21); and (3) massage therapy (MSSG) (n = 20). The treatment consisted of 12 sessions (25 to 30 min each) over an 8-week period. Patients and the treating acupuncturist were blinded. Patients who responded in the acute phase of treatment continued the same treatment for 10 weeks postpartum. Symptoms were assessed using the Hamilton Rating Scale for Depression-17 and Beck Depression Inventory.
At the end of the acute phase, response rates were significantly higher for the SPEC group (69%) than for the NSPEC group (47%) and for the MSSG group (32%). At postpartum, all groups had a significant reduction in depression symptoms. However, the remission rate was significantly higher in the SPEC group (86%) than in the NSPEC group (50%) and in the MSSG group (67%). The authors suggested that acupuncture may be an effective nonpharmacological treatment for depression during pregnancy.22
Use of acupuncture for menopause-related symptoms
Porzio and associates23 evaluated the safety and efficacy of acupuncture for menopause-related symptoms associated with tamoxifen therapy in patients with breast cancer. Whether symptoms were induced by the drug or were a natural effect of menopause was unclear.
Acupuncture was associated with a significant decrease in anxiety (P < .001), depression (P < .001), and somatic (P < .001) and vasomotor symptoms (P = .001). Acupuncture did not modify the participants’ libido.
That study showed acupuncture to be a safe and effective treatment for tamoxifen-induced vasomotor symptoms, anxiety, and depression. The authors emphasized the role of acupuncture only as a complementary therapy-and not as an alternative treatment for breast cancer.23
Acupuncture-associated biochemical and neurophysiological changes
Although acupuncture is becoming more integrated into Western medicine, we still have a very limited understanding of how it works. In a small, uncontrolled study, Dhar and Vasanti24 investigated the effect of acupuncture on the status of thyroid hormones in endogenous depression.
Results showed significant improvement of assessed symptoms (insomnia, depression, restlessness, body aches, and loss of appetite) after acupuncture (P < .05). Baseline abnormal thyroid function tests returned to near normal range at the end of the treatment.
Pohl and Nordin25 studied the effect of EAT on levels of neuropeptide Y (NPY) over 4 weeks in a small pilot study of 6 patients with major depression. During acupuncture therapy, NPY plasma levels decreased in 5 patients. This finding was associated with clinical improvement of depression.
In a trial conducted by Han and associates,26 plasma levels of cortisol and endothelin-1 were studied as biological markers in patients with depression before and after treatment. Cortisol is involved in the “regulation, transcription, activity, and expression” of endothelin receptors. On the other hand, endothelin influences the activity of the hypothalamic-pituitary-adrenal (HPA) axis. Dysfunction of the HPA axis has been implicated in pathogenesis of depression.
Thirty patients were treated with EAT and 31 patients were treated with maprotiline (a tetracyclic). Both groups showed symptom improvements after treatment (P < .01), and no significant difference was found between groups (P > .05). Montgomery-Åsberg Depression Rating Scale scores demonstrated a significantly better adverse-effect profile for acupuncture than for maprotiline. Normalization of the cortisol and endothelin-1 content was observed in both groups (P < .01) without a significant difference between them (P > .05).26 The authors concluded that EAT had the same therapeutic effects as but fewer adverse effects than maprotiline.26
Huang and colleagues27 used positron emission tomography to demonstrate the association between clinical improvements of depression, normalization of cortex-limbic circuitry, and increase in glucose metabolism in different brain regions under the influence of scalp acupuncture.
CONCLUSION
As a therapeutic intervention, acupuncture has become integrated into Western medicine in the treatment of many different medical conditions. However, its practice in mental health is still limited and is often experimental. Despite objective deficiencies, most studies have shown acupuncture to be a safe and promising therapeutic option. It has a more favorable adverse-effect profile than psychotropic medications and is associated with low attrition rates.
Because of the significant number of patients who not respond to or who cannot tolerate conventional treatments for depression, other options must be explored. The data presented here suggest that acupuncture deserves further research as an alternative option for the treatment of depression.
Drugs Mentioned In This Article:
Amitriptyline (Limbitrol)
Fluoxetine (Prozac, Sarafem)
Maprotiline
Mianserin
Tamoxifen (Nolvadex)
http://www.psychiatrictimes.com/display/article/10168/1413274?verify=0
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