Aleta Drummond, MD
Psychiatrist in private practice, Santa Rosa, CA
Dr Drummond has disclosed that she has no relevant relationships or financial interests in any commercial company related to this educational activity.
Is acupuncture a useful alternative therapy for your patients? Perhaps. In 2007, the National Health Interview Survey noted that more than three million American adults were using acupuncture each year to ease chronic pain, a number that is likely to have risen in the past five years. Although acupuncture originated in China, the practice evolved and changed with each culture that adopted it. The many variations in styles may confound clinical studies and make evidence-based practice difficult. Acupuncture is individualized and dependent on variables within each person, so academic studies may be too narrow to capture its significance. The good news is that the volume and scientific rigor of the literature is increasing.
How It Works
Basically, needles inserted at specific acupoints can influence chi (pronounced “chee”), or vital energy, flowing through 12 meridians or channels. The acupoint is an anatomical location where the chi is thought to be more superficial and accessible for the thin, hair-like needle to contact. Obstruction of the flow of chi in these pathways causes physical pain or emotional disturbance, while the treatment encourages a return to homeostasis. Stimulation of the needles is an essential part of treatment and is done manually, with heat, or with electrical current.
The acupuncture needle feels like a transient dull ache, and people can feel relaxed, peaceful, and even fall asleep during the treatment. What causes this sense of well-being? The late Bruce Pomeranz, MD, PhD, hypothesized that the needles placed peripherally stimulate the release of endogenous endorphins, which cause analgesia. Not only did his research group document increased endorphin levels during acupuncture, but they also blocked the resulting analgesia with the morphine antagonist naloxone (Pomeranz B, J Altern Complementary Med 1996;2(1):53–60).
But is it worthwhile in psychiatry to puncture our patients? A double-blind study (reviewed in TCPR, Jan 2007) found placebo or sham acupuncture no less effective than the active treatment for depression (Allen JJB et al, J Clin Psych 2006;67(11):1665–1673). The available evidence base for acupuncture in psychiatry is quite limited (TCPR, Apr 2006).
This is partly because sham acupuncture (used as a control procedure) presents a challenge to researchers. Sham points may also activate the endogenous opioid system, confusing the picture further. However, in one recent study of patients with fibromyalgia undergoing a four-week acupuncture treatment, positron emission tomography (PET) detected short- and long-term increases in mu-opioid receptor (MOR) binding in multiple areas of the brain noted to be involved in pain processing—changes which were absent in the sham group (Harris RE et al, Neuroimage 2009;47(3):1077–1085).
A recent article described acupuncture for pain as “theatrical placebo.” The authors—a neuroscientist and an anesthesiologist—reviewed several meta-analyses and concluded that the small differences noted between active and sham were not clinically significant (Coulquhoun D and Novella SP, Anesthesia & Analgesia 2013;116(6);1360–1363).
But what is wrong with harnessing the placebo effect? Remember, the placebo effect is robust in psychiatry, with some investigators estimating that it may account for as much as 75% of the benefit of antidepressants (Kirsch I et al, PLoS Med 2008;5(2):e45). According to an analysis published in 2006, this observation provides support for the use of acupuncture in many diverse conditions. “If acupuncture alleviates suffering through a powerful placebo effect which theoretically could exceed the total therapeutic effect of conventional therapeutic options,” the author wrote, “it should be accepted as a useful treatment” (Ernst E, J Int Med 2006;259(2):125–137).
Uses of Acupuncture in Psychiatry
So how might you employ this ancient modality in the 21 century? A great place to start is with pregnant patients. A recent study of acupuncture for depression during pregnancy enrolled 150 women with major depression, randomized into active treatment at acupoints thought effective for depression; control acupuncture; and massage. After 12 sessions, the active acupuncture group had a significantly greater response rate than the combined placebo group (63% vs. 44.3%) (Manber R et al, Obstet Gynecol 2010;115(3):511–520).
You might also consider acupuncture rather than a hypnotic for insomnia. A small study in 2004 noted that endogenous melatonin secretion increased while polysomnographic measures of sleep improved with acupuncture (Spence DW et al, J Neuropsychiatry Clin Neurosci 2004;16(1):19–28).
Acupuncture is also being explored for PTSD and stress. A recent animal study of rats who underwent 10 days of cold-induced stress showed that acupuncture (at a point similar to that used in humans, “stomach 36”) caused less elevation in ACTH and cortisol than sham or no acupuncture treatment (Eshkevari L et al, J Endocrinology 2013;217:95–104).
If you can’t envision yourself inserting a needle into your patient’s leg or torso, there’s an entire system of acupuncture that just uses the ear. Auricular acupuncture is based on a somatotopic map of the body superimposed on the external ear. Think of an upside down homunculus when you look at the ear. Tenderness and skin changes correspond to pain or diseases in the body. A seminal experiment found a 75% concordance between the auricular diagnosis and the medical diagnosis in 40 patients with musculoskeletal pain (Oleson TD et al, Pain 1980;8(2):217–229).
Battlefield Acupuncture (BFA), a modified form of auricular treatment, is rapidly becoming a non-narcotic alternative for acute and chronic pain and stress in the military. It was developed in 2001 as a quick and efficient modality to be used in the field (Niemtzow RC et al, Med Acupuncture 2009;21(1):1–4), and the Department of Defense and Veterans Administration have recently received funding to teach and evaluate BFA.
Another easy-to-learn auricular modality is the placement of five needles in each ear to help patients who are in the throes of addiction. Called the National Acupuncture Detoxification Association (NADA) protocol, it has been widely used since the 1970s as part of a comprehensive treatment protocol for addicts. Most patients visibly relax during the time the needles remain in the ear, and for most, craving diminishes (www.acudetox.com). It is used as an adjunct in a multimodal approach to the treatment of addiction.
TCPR’s Verdict: Western scientific inquiry has not yet identified chi, nor dissected the meridians, and evidence is inconclusive as to acupuncture’s efficacy in the treatment of mental illness. Yet somehow it has endured. Whether placebo effect or something more, the benefit of acupuncture can be harnessed as part of effective psychiatric treatment for many patients.