This pioneering book unites both western and traditional Chinese medicine to present a step-by-step methodology for evaluating and treating depression with acupuncture. Using research-oriented trials, it addresses fundamental issues in acupuncture research and offers guidelines for the design of acupuncture treatment studies. Get A Copy. Paperback , pages. Published September 7th by Churchill Livingstone. More Details Original Title.
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- 4 Scientific Studies That Show the Effectiveness of Acupuncture in Treating Depression!
Aug 13, Jenny Stewart rated it liked it. Where are the pictures of the points? I see one for the ear but that's it. More pictures! John Blue rated it really liked it Jul 03, Kody Wallick rated it it was amazing Nov 15, Claire rated it really liked it Oct 24, Jo Mc rated it liked it Feb 03, Spankee Spangler rated it it was amazing Mar 15, Dianna Walsh rated it really liked it Dec 31, Linda L. Randazzo rated it it was amazing Oct 21, Nisaa K marked it as to-read Nov 19, SueBee marked it as to-read Aug 11, Courtney marked it as to-read Feb 23, Jenny marked it as to-read Apr 29, April Heller marked it as to-read Jun 05, Beth Griffing is currently reading it Jun 30, Asnan marked it as to-read Jul 31, Rationale for point selection was not reported by Roschke et al.
All three US trials have used a manualiszed approach developed by Schnyer [ 42 ], which has been published in book format. In theory this looks to be a useful method. It is formulated around individualized treatments on the basis of diagnostic principles that involve looking, asking, listening and touch diagnosis and TCM pattern differentiation. The US studies have separated diagnosis from implementation of acupuncture needling in an innovative attempt to create a triple blind trial blind patient, blind administering practitioner, and blind outcome assessor.
However, the generalizability of the findings is compromised by the fact that the diagnostic skill of only one practitioner has been evaluated. Furthermore it is difficult to make judgements about quality of the intervention because it is not clear from the trial reports how many diagnosticians were involved or what their credentials were for Manber et al. It is not clear from the reports of either of the Allen et al. Thus patient's responses to therapy may not have been used to guide the treatment.
Since implementing practitioners were discouraged from talking to their patients they may not have been able to gage whether there had been problems with the therapy. Additionally, acupuncturists invariably touch their patients, making assessments, particularly about meridians or responsiveness to treatment. It is therefore possible that the potential therapeutic integrity of the intervention may have been compromised by repeatedly using treatments that practitioners in normal clinical practice would have modified or altered because they were seen to be unhelpful.
This limitation equally applies to any study where standardized protocol acupuncture is repeatedly administered. Acupuncture is an iterative process where the practitioner constantly reassesses the patient depending on their response to the treatment. In studies that use standardized protocols, an intervention that may be recognized as unhelpful or inadequate by the practitioner, and would normally be modified in routine clinical practice, would be continued for the duration of the trial.
Furthermore, in the US studies, discrepancies between the information provided to administering practitioners and their blinding, and the reporting of study methods in relation to this, make it difficult, if not impossible, to interpret study findings. In the study it was reported that practitioners were blind as to the study's hypothesis, suggesting they may not have known that the trial was investigating depression.
In the study authors reported that practitioners were informed that the study was investigating points that were directly and indirectly relevant for depression whilst in the trial practitioners were told that the study was investigating various forms of treatment for depression. Researchers concluded that blinding of administering practitioners may not have been entirely successful in this final trial.
It is difficult to know what to make of these studies because in clinical practice practitioners know why their patients have come to them for help and what the purpose of their treatment is meant to be. Communication, which practitioners were requested to keep to a minimum in US studies, is an important aspect of acupuncture care, particularly in cases of depression where patients may require a considerable amount of support from the practitioner.
Authors of the three US studies acknowledge the ecological validity of their research is low and their findings cannot be generalized to standard acupuncture care. The advantage of standardization must be offset against the disadvantage that such treatments, when obviously inadequate or inappropriate, cannot be modified, as would normally occur in routine clinical practice. Finally, in the light of the discussion in the introduction about the many diverse traditions of acupuncture that are practiced in the world today [ 20 ], it is worthwhile highlighting to the reader that all the research attention in the field of depression conducted so far has been focused on TCM methods, and techniques developed from TCM theories.
Other traditionalist methods have yet to be formally evaluated. The next section of the review will examine the comparator arms used by trialists, outlining what these studies can be expected to reveal about acupuncture's potential effectiveness. Apart from the three USA studies, all trials have used a comparator arm intervention of antidepressants see Table 4. Cochrane reviewers have raised concerns that doses were therapeutically ineffective in the Luo trials and the timing of assessment was premature [ 43 ]. In any experimental evaluation it is important that the therapy under investigation is not privileged by providing a therapeutically inadequate comparison.
Roschke et al. Knowing the effect size of an acupuncture intervention in relation to a sham comparator is important to avoid a false negative result [ 44 ]. All three US studies, the first of which [ 28 ] was described as a pilot study, have employed what is described as a nonspecific acupuncture comparator arm, where acupuncture points that were not thought to be therapeutically appropriate were needled. Although the Allen et al. It is not clear what points were used, why they were chosen, and whether they varied from patient to patient or between treatment sessions.
Subjecting depressed pregnant women to a theoretically inappropriate treatment, which has apparently achieved worse outcomes than no intervention at all in piloting work, is possibly ill advised. But in clinical practice acupuncture practitioners and massage therapists do not have to keep verbal interactions to a minimum, and use verbal interaction to gain and maintain rapport with their patients.
The final section of the review will be on outcomes. What instruments were used and when measurements were taken, an overview being shown in Table 5. As was discussed in the introduction section, researchers have emphasized that an intervention for depression should be evaluated according to its capacity to offer protective benefits, as well as to achieve a more rapid or improved remission from a specific episode [ 16 , 45 ]. Because of the chronic episodic nature of depression, the potential economic advantages of an intervention are likely to become more apparent in the long term if the intervention can prevent relapse in addition to achieving remission in the short term.
With the exception of Manber et al. In terms of outcome measures Table 5 shows that the Hamilton Rating Scale for Depression has been used as the primary outcome measure in all studies apart from Roschke et al. The Luo et al. How patients were selected for these tests was not reported. Broader outcomes of acupuncture, such as quality of life, and economic benefits of the intervention have not been explored. In clinical practice it would be unusual for acupuncture to be focused solely on a specific medical condition, and a wide range of health benefits, are normally be expected from treatment.
For example it would be expected that a female patient with depression who also suffered with irregular or painful menstruation would find that her menstrual cycle became more regular and less painful. From the patient's perspective, the potential benefits of acupuncture for individuals with chronic illnesses have been investigated by Paterson and Britten with changes falling into three main categories: changes to health status including improvements to a specific condition and improved strength and energy; changes to social and personal identity; and changes to medication use [ 46 ].
Ideally, a range of measures are likely to be required to capture the potential benefits of acupuncture [ 47 ]. The study population, intervention, comparison s , and outcomes of nine trials have been evaluated with our review highlighting a number of study limitations, quite apart from methodological considerations that prevent bias and confer reliability. One of the main concerns is that in attempting to evaluate replicable treatments, interventions have been standardized, and protocol acupuncture, where individuals receive the same or similar points without modification during the course of the trial have been investigated.
What happens during an acupuncture treatment?
Acupuncture care that is modified in line with patient's responses, as would occur in routine clinical practice, has not been evaluated. Secondly, in some trials where a flexible protocol was evaluated, notably where the quality rating was highest according to Cochrane reviewers, treatment was administered by practitioners who were discouraged from talking to their patients and did not appear to know, according to trial reports, exactly why they were treating them. Concerns were raised about the use of therapeutically inappropriate treatment as a safe or useful comparison.
It is possible, given individual variations in responsiveness to acupuncture, there may be a degree of unpredictability about this intervention that makes it unsuitable for comparative purposes. Protective benefits of acupuncture care were not investigated, yet, as was highlighted in the introduction, this is where the economic benefits of a depression intervention may be most apparent.
Additional research costs associated with longer term treatment and follow up can and should be offset against the potential reduction in the cost to society, and suffering caused to individuals, of repeated illness episodes. Authors suggest that model validity is crucial for whole systems research and unconventional therapies such as acupuncture where philosophical assumptions may differ from those of biomedicine. Four criteria have been proposed for assessment of model validity by Verhoef et al.
These are: representativeness —whether the intervention is consistent with current practice, likely to produce and effect and clearly described; equipoise and credibility —to assess equipoise on the part of patients and practitioners with respect to the intervention under investigation and its credibility in relation to expected treatment effects; model congruity —to assess whether the diagnosis, intervention and outcomes fit the system under investigation, and finally context —to assess patient and practitioner confidence in the intervention and whether the intervention was sensitive to the culture, family and meaning that the patient ascribes to an intervention.
Clearly, the nine trials in this overview fall short on these criteria. The problem is that the potential value of TCM acupuncture as a depression intervention will remain unknown if evaluations do not allow practitioners to implement their therapy as they would in everyday clinical practice.
However, it is not just acupuncture trials of depression that have been criticized for providing inadequate information on which to base decisions about provision of care. RCTs of antidepressants have also come in for criticism because medications produce different results in tightly controlled trials than they do under normal practice conditions [ 49 ]. Research has also revealed how it can be extremely uncomfortable for practitioners to participate in explanatory trials of acupuncture because of being aware that the patient is receiving what is thought to be inadequate treatment and needing to conceal this fact from them in the context of trying to maintain a close therapeutic relationship during a number of therapy sessions [ 51 ].
Evidently nonspecific interventions involving the insertion of needles are more potent than placebo pills [ 52 ]. Although acupuncture's theories remain unproven it is questionable whether it is in the best interests of patient safety for these theories to be completely disregarded, and needles inserted into therapeutically inappropriate locations, particularly in the case of patients who are pregnant, and obviously have a high risk of suicide as a result of their illness. If acupuncture hypothetically has the potential to heal does it not hypothetically have the potential to harm if inappropriate treatment is given?
How Acupuncture Can Relieve Pain and Improve Sleep, Digestion and Emotional Well-being
One way forward for future research is to evaluate acupuncture as the complex intervention that it is. In certain respects acupuncture is similar to counseling or psychological therapies in that the therapeutic relationship, which develops over time, cannot be separated from the intervention. This relationship is built on patients feeling comfortable with their practitioner and the explanations of illness specific to Chinese medicine their practitioner offers. Guidelines for complex intervention evaluations such as psychological therapies and health education interventions have been put forward by the Medical Research Council [ 53 ], and may be of interest to trialists thinking of how best to evaluate traditional acupuncture.
One of the most challenging aspects of conducting complex intervention research is undoubtedly the standardization of the intervention, which should according to researchers, be done on the basis of function rather than form [ 54 ]. But researchers will need to meet the challenge if they are to evaluate acupuncture in such a way as to be reflective of clinical practice. Trials of specific acupuncture protocols are nevertheless of interest as they, when methodologically sound, offer convincing evidence of the potential for specific acupuncture techniques to be beneficial, and when brain scan research demonstrates biological changes resulting from interventions as suggested by the most recent systematic review [ 33 ] this is likely to give acupuncture more credibility as a potentially useful intervention for depression.
Depression is a huge and increasing problem that costs society a great deal of money, and impacts on many individuals, directly and indirectly.
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Research is required that can actually inform patients and service commissioners as to whether the treatment they might, in practice, receive from a therapist is potentially likely to be of any clinical value, and whether it may be harmful. Trials of acupuncture are needed that investigate the effectiveness of acupuncture, in such a way that the potential therapeutic integrity of the intervention is not compromised by the evaluation method, whilst maintaining the rigor of the evaluation. A recommendation of this review is that research is conducted in the field of depression with better model validity, and that can be of more practical value for informing decisions about provision of care.
Unless acupuncture is evaluated using methods that do not compromise its potential therapeutic integrity by limiting its evaluation to specific acupoints applied outside the context of a proper Chinese medical diagnosis, uncertainty will remain about whether it can truly be effective or not for treating depression. Thanks also to Karen Smith who provided advice on searching the literature and to Wenqing Li who translated two Chinese articles into English. Volume 17 , Issue 5.
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Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Introduction Depression is a major problem for the world today. Study Selection Study selection was based on those selected for inclusion in a Cochrane review, with the addition of two further studies [ 26 , 27 ]—because the research team responsible for the highest quality trial in the Cochrane review [ 28 ] had been conducting further research, and it was decided to include their subsequent studies in the review.
First author and year Interventions Results Luo et al. Amitriptyline Both groups significantly improved, no significant difference between them Luo et al. Amitriptyline No significant difference between EA and Amitriptyline on primary outcome measure. Biochemical markers were different for intervention and control Xiujuan et al. Phase 1: Electro acupuncture plus placebo medication; amitriptyline; electro acupuncture plus amitriptyline. Phase 2: two groups, EA plus placebo or amitriptyline Only phase 1 was reported in Smith and Hay Cochrane review, phase 2 appears to be a duplicate of Luo Phase 1 — no significant difference between groups.
Phase 2 — no significant differences between groups on primary outcome measure but EA had less side effects. Factor analysis showed EA better for anxiety somatization, cognitive disturbance and treatment of reactive depression than amitriptyline. Biochemical study showed plasma nor epinephrine changed greatly after EA treatment. Mianserin Patients receiving both types of acupuncture improved slightly more than those receiving Mianserin only Han et al. Maprotiline Both groups significantly improved, no significant difference between them Manber et al.
Both were significantly better than massage Allen et al. The Study Population Study populations or patient groups are summarized in Table 2. Trial first author, date Patient groups 1. Luo et al. Duration of disease ranged from 4 months to 5 years 4. All participants were drug free for the week before commencing the trial. Mean age was 36 years and mean course of depression 7.
In the second phase of research see Ref. Patients with coagulation disease, wound healing disease, emphysematous thorax, abnormal blood cell count, serious liver and kidney disease, epilepsy. Participants recruited from obstetric clinics and local magazine advertisements. Participants were recruited via newspaper advertisements that mentioned depression but not acupuncture, responded between January and March Trial first author, date Acupuncture Intervention 1. Du 20 and Yintang were points used 2.
Needles inserted obliquely 2—3 cm under the skin. Participants received six sessions a week for 6 weeks. These were developed according to a treatment manual by the assessing acupuncturist Schnyer. Patients were assessed by one acupuncturist whilst four others provided treatments. Practitioners were ostensibly blinded as to whether patients were receiving specific or nonspecific acupuncture, having rated their beliefs in treatment efficacy similarly for both types of intervention.
Treatment involved twelve sessions over 8 weeks. Delivered by 2 clinicians Standardized whole body treatment, three times per week over four consecutive weeks. Each session lasted 30 minutes, each patient being seen by the same practitioner.
Points were U. These were developed according to a treatment manual developed by Schnyer. Patients were assessed monthly by one acupuncturist whilst others provided treatments. Responders received additional treatments 9. Patients were assessed by one acupuncturist whilst four others provided treatments which involved twelve sessions over 8 weeks. Comparator Arm Interventions Apart from the three USA studies, all trials have used a comparator arm intervention of antidepressants see Table 4. Trial first author, date Comparator Arm s 1.
Luo China Amitriptyline medication for 6 weeks. Initial dose for week one: 25 — 50 mg, increased to mg per day. From week 2 the dose was modified depending on side effects. Xiujuan China Amitriptyline 25 mg on the first day, dose increased by 25—50 mg each day up to mg. In the second week the dose was adjusted according to response and side effects but ranged between and mg per day 4. Luo China Phase 1: Amitriptyline treatment group received average dose of mg per day, combination group received mg per day. Phase 2:Amitriptyline given at average dose of mg per day.
Allen USA Two comparator arm interventions: Nonspecific acupuncture using acupuncture points but for another diagnosis e.
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The nonspecific acupuncture and wait list control groups received specific acupuncture after 8 weeks. Administering acupuncture practitioners were blind as to study's hypothesis. Roschke Germany Three groups Mianserin 90— mg per day Mianserin 90— mg per day plus verum acupuncture Mianserin 90— mg per day plus placebo acupuncture Placebo acupuncture patients received treatment at nonacupuncture loci adjacent to the selected acupoints and the skin was only superficially pricked.
Han Maprotyline medication, daily dose ranging from 75— mg, for 6 weeks 8. Administering acupuncturists were told the study was investigating points that were directly and indirectly relevant for depression. Administering acupuncture practitioners were told the study was investigating various forms of treatment for depression.
Trial first author, date Outcome measures measures used and when measured 1. Participants interviewed by 2 psychiatrists ant beginning and end of trial 5 weeks , and at weekly intervals during the trial 2. A proportion of participants had urine and plasma tests and EEG tests 3. EEG measures used for acupuncture subjects only at baseline, after 1st, 18th and final needling 4.
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A proportion of participants had urine and plasma tests and EEG tests in 2nd phase of research 5. Rated by psychiatrists blind to allocation twice a week for 8 weeks 7. Baseline, 14, 28, and 42 days after treatment commenced 8.