Acupuncture in management of moderate to severe depression.
Acupuncture, an ancient therapeutic technique, is emerging as an important modality
of complementary medicine in the treatment of psychological diseases. If one protocol
existed for treatment of depression with acupuncture regardless of their Chinese Medical
diagnosis, it would certainly accelerate researches and incorporation of acupuncture into
conventional medicine. In this article all the patients were diagnosed by DSM 4 and were in
the range of moderate to severe. The treatment of acupuncture had been performed by one
protocol for all of them.
To describe the outcome of patients with major depressive disorder diagnosis with
moderate and severe types that received acupuncture treatment.
Design, Setting and Patients
Case series of 60 patients that used acupuncture for treatment of Major Depressive
Disorder of moderate to severe; that their diagnosis made by using criteria of DSM 4. The
treatment and follow up performed from Mar/2006 to Jan/2008.
10 treatment sessions: every other day for 5 treatments, every week for 3 treatments
and every other week for 2 treatments. Treatment consisted of nearly 20 acupuncture points,
based on one formula for all of them. Needles placed bilaterally and De Qi was obtained.
Main outcome measure
Principally improvement of depressive symptoms and underwent Hamilton Depressive
Scale in the beginning and in the end of the course. For those that considered being in full
remission should have improvement of 7 or more in HDSD and at least two months without
7 patients did not complete the course and 53 of them completed the treatment
(88.3%). 5 of them did not respond and the rest of them were in full remission based on the
DSM 4 (80%).
Acupuncture is an effective modality in the treatment of moderate to severe
depression, regardless of duration of disease.
DSM 4, Hamilton Depressive Scale for Depression, Zang-fu organs, and liver yang.
Although, undergoing TCM diagnosis procedure is essential in the treatment of patients
when choosing acupuncture treatment for them. But it seems that in-patients with the
conventional medicine diagnosis of depression of moderate to severe threshold because the
derangement due to consumption of liver yin by hyperactivity of liver yang or liver Qi
stagnation, is not merely one organ system involvement, in the treatment all organ system
should be targeted unless treatment would not be successful. All the symptoms in the
depression with the magnitude of moderate to severe can be explained by TCM as
derangement of several Zang-Fu organs. Therefore, treatment approach should be regulation
of Qi in every of them. For this reason in the protocol of treatment every of them are
targeted and the diagnosis based on TCM can be omitted. Although, the diagnosis process in
TCM by using pulse and tongue diagnosis and history taking can make diagnosis of
depression without need to use any other means. But in order to accelerate incorporation of
acupuncture into main stream medicine and even in acupuncture treated group with the use
of one protocol leads to near to similar effect; existence of one treatment protocol for the
disease like depression is a necessary objective.
Here some data about prevalence of depression today and in future.
Research suggests that 1 in 4 people will experience some kind of mental health problem in
the course of a year. (Bird, 1999). A 1993 study estimated that depression alone costs 3
billions pounds each year in England when lost productivity and the cost of welfare benefits
are taken into account, with direct cost to the National Health Service estimated at 420
million pound per year (Kind and Sorenson, 1993). While conventional treatments like
psychotherapy and medication alleviate the blues in a whopping 50% to 70% of patients who
complete the regimen, about one-third of those who begin therapy never complete it because
they see no improvement or experience debilitating side effects. Even among people who do
recover from depression, more than one-third relapses within 18 months. (Psychology Today,
Sep, 1999 by C.C.)
Several facts exist today; first its’ current high incident, another one is expectation of increase
of it in future; the last one is unsatisfactory result from existing drug therapy. Another
effective approach is highly necessary and when this effective approach does not have any
important side effect and has been used for several centuries’ looks lucrative. But the
researchers and clinicians do not have one protocol that can lead to a similar result in one
group of depressed patients. It seems that when the treatment given by one protocol can
effectively hinder the existence problem in incorporation of acupuncture in the treatment of
depression. The clinician and researcher expect to see similar result in similar intervention.
From the 60 aforementioned patients brief history of five of them will be presented. All of the
patients that have been treated got inform consent in the beginning of therapy and agreed to
be participated in series report without directly mentioning their personnel information.
Case number 1:
This patient was 41, male, married and had three children at the time for interview. His
symptoms were worthlessness, anhedonia, insomnia, severe agitation, fears, total loss of
functioning and besides them feeling of guiltiness. He was agitated, responded to the
questions with delay and in questioning had libido. And he was very suspicious, lost 5 kg of
weight and did not accept that had depression.
He had an interview with psychiatrist and was referred him for hospitalization but he did not
accept. And after a short period of drug treatment discontinued them because of side effects.
His diagnosis based on DSM four was Major Depressive Disorder, Single Episode, and Severe
with melancholic features.
The date of first interview was 10/6/2007 and in the same day the treatment begun.
Hamilton Rating Scale for Depression at the first interview was 32 and two months later after
receiving ten sessions of acupuncture was 20. He was in full remission 2 months later and 6
Case number 2
The patient was 50, female, married with a chronic history of major depressive disorder. The
date of first interview was 18/ Apr/2007. The past history consisted of near to 21 days of
hospitalisation and 6 courses of electroconvulsive therapy twelve years ago, several
attempted suicides. And she has been constantly with two or three antidepressant and
antianxiety drug therapy. But as she said with full dosage of several of them, only her
symptoms subsided mildly.
Her conventional medical diagnosis based on DSM four was; Major depressive Disorder,
Chronic, severe without psychotic features with Hamilton Depressive Scale of 32 at the first
day of interview. She was on the drug therapy by psychiatrist with combination of SSRI and
Tricyclic Antidepressant and Antianxiety agent, in the time of first interview. The method of
treatment for this patient because of chronically and depletion of kidney yin besides the
protocol was consisting of KD 3 too.
She was in complete remission two months after beginning of therapy and six months later.
). Her Hamilton Depressive Scale two months later in 17/June was 22 following the therapy
with acupuncture. In telephone conversation with her, she was satisfactory and has been
without any drug therapy (in the date of 20/Feb/2008). She was complaining about her affect
but she said that it did not require therapy and did not interfere with her life (mild remnant
Case number 3
The patient was a male of 40 with over 15 years of depression, date of first interview and
beginning of therapy was at 14/May/2007. He received several courses of drug therapies. But
he lost his job in the beginning of disease and has been in cover of special welfare
organization because of inability to work. His conventional medicine diagnosis that performed
by several psychiatrists was; major depressive disorder, chronic, severe without psychotic
He resumed a new job one-month after beginning of therapy and in his follow up was in full
remission. His HDSP in the first interview was 30 and dropped by 8 after two months of
receiving the therapy.
Case number 4
This patient was 36, female, recently discharged from psychiatric hospital. And although, she
was on the treatment for over one-month her depressive symptoms were not subsided. Her
DSM diagnosis was MDD, Single Episode, and Severe without psychotic features.
After five sessions, she decided to discontinue the drug therapy because of side effects and
her condition improved. Her first interview and HRSD was 26 and the date was at the
18/June/2007 and two months later it was 18. She remained in full remission six months
Case number 5
The patient was a female, married, and 32. Her depressive disorder was chronic with near to
10 years of duration. And she hospitalized for several times and the last time was in last year.
In which she received 10 sessions of ECT. Until the date of first acupuncture session that was
at the time of first interview, was under drug therapy.
The date of first interview was at the 5/Jul/2006 and in that time HRSD was 30. She was
under drug treatment at the time of first interview. The treatment had been begun at the
date of first interview and received 10 sessions of acupuncture treatment and her HRSD two
months later decreased by 10 and was 20. In the follow up six months later, one year and
last time at the 19/Feb, her condition was stable.
In this protocol all affected Zang-Fu organs is deliberately targeted in acupuncture
treatment. The most frequently used points were; ST 36, ST 25, SP 6 for harmony of
spleen and stomach; GB 34, LR 3 for dispersing the liver; Du 20, Sishenchon for
soothing their minds and improve circulation of Qi in the whole body. And other
points were CV 12 for strengthen yang meridian of stomach; CV 6 for strengthen of
stomach and spleen and tonification of Qi; HT 7 for tonification of heart Qi; and the
acupoint LI 4 because in accompany with LR3 improve the circulation of Qi and
blood. In the chronic patients with depression because of Qi of kidney is also altered
by the long standing disease and their pulses loss their root, therefore, in them KD 3
had been used.
The male proportion in this series was 16 male (26.6%) and female proportion was
73.4%. Nine patients were in single episode (15%) of patients and 51 of them were
chronic (85%). Twenty of them were moderate (33.3%) and the rest of them were
severe (66.7%). Two of them were with congruent psychotic features (3.3%) and 16
patients were with atypical features (26.6%). 48 (80%) patients completed the courses
and were in full remission (for at least two months without symptoms) and 5 of them
were incompletely treated and 2 were not responded and 7 were not complete the
It seems that use of acupuncture in this intractable disease with such lower rate of side
effects and high rate of success could be justifiable. Although, for confirmation of it
more research in the greater population, randomized and double blinded is necessary.
By incorporation of this method of treatment when eligible by the further research
could revolutionize the treatment of major depression of moderate to severe in future.
Even though, some randomized research performed especially more prominent one at
University of Arizona and in Tucson. But the matter is that the patients with
depression had mild to moderate type of depression. Those types more affected by
society and by learning helplessness from society (as some psychologist described).
Although, results in comparison with drug therapy are encouraging. But future
researches should compare acupuncture treatment in those with moderate and severe
types with other ways of therapy and using the proposed protocol in this article can be
a milestone in this regard.
Another research that mainly focused on scientific documentation of effects of acupuncture on central
nervous system that performed at Massachusetts general hospital, department of radiology. They
stimulated a point that was LI4 and performing fMRI. They quoted “We hypothesize that modulation
of subcortical structures may be an important mechanism by which acupuncture exerts its complex
multisystem effects”. Therefore, acupuncture effects on depression should be exert its’ effects via
central nervous system.
With through scientific researches may be the rate of compliance could be increase. In
this series, the main reason for quitting of therapy (in seven patients 20% of cases)
was lack of sufficient scientific resources about the affectivity of acupuncture on their
disease. Even though, all of them got inform consent about treatment but it seems that
they accept the acupuncture treatment as last resort and may be seeing similar treated
patients, could be a motivation force for them.
Because of the below fact the research upon effectiveness of acupuncture on
depression should be in long duration.
Eighty to 90 percent of individuals will remit within 2 years of the first episode (Kapur & Mann,
1992). Thereafter, at least 50 percent of depressions will recur, and after three or more episodes the
odds of recurrence within 3 years increases to 70 to 80 percent if the patient has not had preventive
treatment (Thase & Sullivan, 1995).
In this article only tried to represent a viable, acceptable way of treatment of this
disease with acupuncture and for so many questions that remained, hope that further
researches can answer them. But when in some cases in this study several
hospitalisation and even in some electroconvulsive sessions were not successful and
several acupuncture sessions can lead to better outcome, the scientific community in
this field of medicine should begin their study and confirmation of it with haste.
Another significant matter in treatment group is even though, their depression based
on criteria of DSM4 treated but some remnant depressive mood remained. It can be
concluded that for treatment of reservoir depression and gaining full recovery
working statue, it should be complemented with other treatment options like
psychotherapy. Even it may be better to treat mild depression with the mixture of
acupuncture and psychotherapy. Even though, the result was encouraging but without
further research it can not corollary related.
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