Acupuncture for the Winter Blues
Acupuncture improves antidepressant response and is safe for pregnant women.
Posted Dec 20, 2018
This post is part of a series on alternative and integrative treatments of depressed mood. Previous posts in the series reviewed research findings on anti-depressant benefits of SAMe, folate, vitamin B-12, omega-3s, DHEA, bright light exposure therapy, and exercise. This post is on acupuncture as a treatment of depressed mood. Acupuncture has been a central part of Chinese medicine for millennia and is widely used around the world to treat a variety of medical and mental health problems.
Mechanism of action
From a Western medical perspective the antidepressant effects of acupuncture may be mediated by nerve impulses transmitted at the point of needle insertion in the skin to the hypothalamus and other brain regions stimulating the release of norepinephrine, serotonin, dopamine, β-endorphin, enkephalin and possibly other neurotransmitters. According to Chinese medical theory, symptoms of depressed mood reflect deficiencies or imbalances in qi energy in certain meridians or organs.
Review of research
Findings of several sham-controlled double-blind studies support that acupuncture, including conventional manual acupuncture, electroacupuncture, laser acupuncture, and ear acupuncture (i.e. ariculotherapy) has antidepressant effects, however other sham-controlled studies report negative or equivocal results. These differences may reflect methodological problems inherent in designing studies on acupuncture related to heterogeneity in the severity of depressive mood symptoms being treated, high rates of comorbidity in many studies, concurrent use of other alternative therapies or medications in patients receiving acupuncture, and the use of different acupuncture treatment protocols depending on the energetic formulation (MacPherson 2004).
A meta-analysis of 13 studies comparing acupuncture vs an antidepressant plus acupuncture in in depression found that individuals receiving combined treatment responded better--and more rapidly-- compared to individuals treated with an antidepressant alone (Chan 2015). The authors of a systematic review on acupuncture for depression concluded reported that acupuncture significantly reduces the severity of depressed mood symptoms (Wang 2008). However, the authors of a subsequent systematic review that included more studies found low quality evidence for an antidepressant effect of acupuncture (Smith 2018) when used alone or in conjunction with an antidepressant. The authors commented that significant variations in outcomes of individual studies may depend on differences in study design, the severity of depressive mood symptoms being treated, the acupuncture protocol used, and antidepressant medication being compared to acupuncture. In addition to the above factors, findings of meta-analyses may also reflect cultural and ideological differences between researchers in different countries as well as differences in publication bias in medical journals published in China and Western countries.
Findings of a small double-blind sham-controlled study suggested that traditional manual acupuncture (ie, in the absence of electrical current) may be an effective treatment of severely depressed outpatients (Allen 1998). By the end of this 8-week study 68% of 33 female outpatients being treated with an acupuncture protocol directed at depressed mood had achieved full remission. The significance of these findings is limited by the fact that depressed women patients who were not receiving any treatment in a wait-list group showed equivalent improvement in depressed mood.
In a large six week multi-center study 241 depressed inpatients were randomized to receive electro-acupuncture plus placebo versus electro-acupuncture plus the antidepressant amitriptyline (Luo 1998). Both groups experienced equivalent improvement in depressed mood. It is interesting that patients treated with electro-acupuncture had significantly elevated plasma norepinephrine concentrations following a six-week course of treatment consistent with the hypothesis that electro-acupuncture may stimulate release of norepinephrine in the brain. Depressed patients who failed to respond to electro-acupuncture did not show significant changes in serum norepinephrine levels. Findings of a several studies support that acupuncture is a safe and effective treatment of depressed mood in pregnant women (Manber 2004; Sniezek 2013). In addition to its beneficial effects as an add-on therapy, emerging findings suggest that acupuncture may reduce the incidence of sexual side effects to antidepressants (Wu 2012).
A recent innovation in acupuncture uses computer-guided modulation of the frequency and waveform of the current delivered through acupuncture needles. Findings from open trials of computer-controlled electro-acupuncture (CCEA) suggest that high frequencies (1,000 Hz) yield responses in depressed patients that are superior to both conventional acupuncture and electro-acupuncture (Luo 1996).
Few safety issues
Acupuncture generally causes transient minor side effects such as soreness and bruising. A meta-analysis of studies of complications related to acupuncture identified infrequent cases of infection with HIV, hepatitis B and C due to use non-sterilized needles. Rare cases of pneumothorax and cardiac tamponade have been reported as a result of accidental puncturing of lungs or the pericardium (Ernst 1997; Wang 2018).
After decades of research, the evidence for acupuncture as a stand-alone therapy for depressed mood remains inconsistent however increasing numbers of well designed sham-controlled studies show efficacy. Differences in outcomes in different studies can probably be explained by the large variety of acupuncture techniques (manual, electroacupuncture, ear acupuncture and laser acupuncture) and protocols used, as well as subtle psychological, cultural and biological factors that translate into response differences and are difficult to characterize in Western medical terms. Accumulating research findings suggest that acupuncture may have significant adjunctive effects when combined with antidepressant therapy. Many studies support that acupuncture is a safe and effective treatment of major depressive disorder in woman and emerging findings suggest that acupuncture may help reduce the incidence of side effects caused by SSRIs and other antidepressants, including sexual side effects.
On the basis of the above, acupuncture should be regarded as a reasonable choice for depressed individuals who fail to respond to antidepressants, pregnant depressed women and for depressed individuals who are seeking non-pharmacologic ways to deal with medication side effects.
Chinese Medical Psychiatry: A Textbook and Clinical Manual, Flaws & Lake, 2000