J. Lake, M.D.
(NOTE: these comments and recommendations are directed toward Western physicians who treat mental and emotional symptoms)
Consider referring a depressed (non-suicidal) patient to a Chinese medical practitioner who is qualified to use acupuncture, electro-acupuncture or herbal medicines to treat this condition.
Specific recommendations:
Consider referring patients with depression to specific Chinese medical practitioners who have specialized training in the use of acupuncture, electro-acupuncture, or herbal medicines for treatment of depressed mood.
Continue to follow and evaluate depressed patients who are receiving Chinese medical treatments, and with the patient’s consent, exchange pertinent medical or psychiatric information with the Chinese medical practitioner.
In general, avoid concurrent use conventional synthetic anti-depressants and Chinese herbal medicines because, unlike many Western herbal medicines, most Chinese herbals have not been completely characterized as to active constituents, making assessment of risk of interactions difficult. Consider conventional synthetic anti-depressants for patients who are receiving concurrent acupuncture or electro-acupuncture treatment for depressed mood or other indications.
Discontinue Chinese medical treatments in any patient who becomes suicidal and admit for emergency psychiatric evaluation.
In moderately or severely depressed patients who have failed previous therapeutic trials of conventional anti-depressants or psychotherapy, consider referral to specific qualified Chinese medical practitioners if available in the local community.
In moderately or severely depressed patients who have failed previous trials of Chinese medical therapies for depressed mood, refer to a qualified psychiatrist or psychotherapist.
Encourage non-suicidal depressed patients who do not have co-morbid personality disorders or psychotic disorders to consider undertaking the practice of QiGong under the guidance of a skilled teacher.
Rationale:
Chinese Medicine includes two major symptom patterns that are associated with depressed mood changes. One pattern, “liver qi depression,” is similar to “agitated depression” in Western psychiatry. The other pattern, “qi vacuity,” is similar to “vegetative depressed mood.” The Chinese medical system of classification includes many disorders characterized by depressive mood changes. These include, principally, “Frequent Sorrow,” and “Withdrawal and Mania.” These diagnostic categories in Chinese medicine are similar though not equivalent to Major Depressive Disorder and Bipolar Disorder, respectively. Specific acupuncture and herbal treatments are used to address different symptom patterns.
Many case reports and few open trials and double-blind controlled studies show that acupuncture stimulation of certain acupuncture points validated in Chinese medicine consistently improves mood in mildly to moderately depressed patients.
Some double-blind sham-controlled studies show that certain acupuncture protocols achieve symptomatic relief that is comparable to conventional anti-depressants or psychotherapy in mildly to moderately depressed outpatients.
Preliminary evidence from case studies and some double-blind placebo-controlled trials has shown that electro-acupuncture treatment of specific points using certain prescribed protocols is as effective as amitriptyline in depressed patients.
Preliminary evidence suggests that computer-controlled electro-acupuncture (CCEA) is even more effective in the treatment of depressed mood than conventional acupuncture or non-computer-controlled electro-acupuncture.
Anecdotal reports and preliminary evidence from a few small studies suggest that positive emotional changes, including improved mood, take place when Qigong is consistently practiced. One double-blind study and two small prospective open trials showed positive effects on mood related to long-term consistent practice of certain QiGong exercises. There were no noted side effects or contraindications.
Evidence:
- Many controlled studies and case reports show consistent positive effects of acupuncture, electro-acupuncture and Chinese herbs in the treatment of depressed mood. These studies, and the theory supporting Chinese medical treatments of depressed mood are reviewed in two recently published textbooks. (Flaws, B., and Lake, J. Chinese Medical Psychiatry: A Textbook and Clinical Manual, especially Book II, Ch 1 and 5; and Book III, Chs 4 and 6, Blue Poppy Press, 2001; Schnyer, R., Allen J. Acupuncture in the Treatment of Depression: A manual for Practice and Research, Churchill Livingstone, 2001).
- A pilot study (Allen, J., Schnyer, R., Hitt S. The efficacy of acupuncture in the treatment of major depression in women. Psychological Science, 9(5):397-401, 1998) randomly assigned 33 female outpatients who met criteria for major depression to one of three groups: acupuncture treatment specific for depression; a non-specific treatment using valid acupuncture points; and a “wait-list” condition where patients received no treatment for eight weeks. 64% of patients who received acupuncture treatments specific for depression (Allen, et al 1998) showed full remission, and improved significantly more than women in the non-specific treatment group, but did not show greater improvement than women in the “wait-list” group.
- A pilot study (N=29) of depressed inpatients (Guangzhi, L. et al Electroacupuncture treatment of pre-senile and senile depressive state, J. Traditional Chinese Medicine 12(2): 91-94, 1992) was followed by a large multi-center study (Hechun, L. et al Electro-acupuncture in the treatment of depressive psychosis: a controlled prospective randomized trial using electro-acupuncture and amitriptyline in 241 patients, Intl. J. of Clinical Acupuncture 1(1):7-13, 1990) of depressed hospitalized patients at ten psychiatric hospitals (N=241) randomized to two treatment groups: electro-acupuncture + placebo and electro-acupuncture + amitriptyline (Luo, H, et al Clinical research on the therapeutic effect of the electro-acupuncture treatment in patients with depression, Psychiatry and Clinical Neurosciences 52 (Suppl.), S338-S-340, 1998). Both the pilot study and the multi-center study were six weeks long, and both showed an equivalent anti-depressant effect of electro-acupuncture and amitriptyline.
- Factor analysis using the Hamilton Rating Scale for Depression (HRSD) showed that electro-acupuncture was superior to amitriptyline when there was co-morbid anxiety.
- There is preliminary evidence that the mechanism of action in electro-acupuncture is stimulation of norepinephrine release in the central nervous system (Riederer, P, Manipulation of neurotransmitters by acupuncture (a preliminary communication) J. Neural Transmission, 37:81-84, 1975.). Plasma norepinephrine concentrations were significantly elevated in depressed patients who improved following a six-week course of electro-acupuncture. Non-responding patients did not show significant changes in serum norepinephrine levels (Fanqiang, M, et al Plasma NE concentration and 24 hour urinary MHPG-Sov excretion changes after electro-acupuncture treatment in endogenous depression World J. Acupuncture and Moxibustion, 4(2):45-52, 1994).
- Preliminary evidence from open trials of computer-controlled electro-acupuncture (CCEA) suggests that high frequencies (1,000 Hz) resulted in superior responses of depressed patients treated with electro-acupuncture (Hechun, L, et al A control observation on therapeutic effects of intelligent (computerized) electro-acupuncture and common electro-acupuncture treating 77 cases of neurosis, World J. Acupuncture and Moxibustion, 3(2): 25-28, 1993; Hechun, L, et al Advances in clinical research on common mental disorders with computer controlled electro-acupuncture treatment, Neurochemistry in Clinical Applications, ed. L. Tang and S. Tang, Plenum Press, New York, 1995, pp. 109-122.).
- An observational study (Tang, C. et al, Effects of QiGong and Taijiquan on reversal of aging process and some psychological functions, 3rd National Academy Conf. On Qigong Science, 1990) (N=260) on the efficacy of QiGong or Taijiquan as treatments of “neuroticism,” showed that indicators of anxiety, quality of sleep, and overall “neuroticism” were significantly lower in patients who had consistently practiced QiGong or Taijiquan for at least five years compared to individuals who had not practiced either mind-body technique. Two open studies (Wang, J., Psychological effects of QiGong, 1st World Conf. Acad Exch Med; Schwartzman, L., Tai Chi and Parkinson’s Disease, 2nd World Congress Qigong, 1998) showed improved mood in depressed patients when QiGong was practiced consistently for at least two years. One study examined the effect of Qigong practice on depressed mood in elderly patients with Parkinson’s disease. Both studies showed that improved mood was associated with overall improvements in baseline emotional state.