Acupuncture and Depression
I have been using acupuncture for over 25 years and one of the reasons for doing my advanced training in China was to examine its use in neurological and psychiatric disorders.
It was interesting to discover that even in hospitals specializing in traditional Chinese medicine, the doctors usually used conventional antidepressants and antipsychotics rather than acupuncture, although I had seen many Western acupuncturists claim that they could treat depression.
My own experience with treating acupuncture has been disappointing. By contrast, it is often very good indeed for anxiety, and I have shown many people how to follow up with simple acupressure if they experience anxiety or panic.
There is new research that seems to endorse my lack of success in treating depression and why the Chinese doctors used Western medicine.
There had been a number of small studies (e.g. 1. 2. 3. 4. 5. 6.) of acupuncture in depression that had shown promise, as well as some huge Chinese studies that had claimed good results.
One of the problems with much of the Chinese research is that it is normally done without control groups and with very broad criteria. Many only rate whether someone is “cured,” “much better” or “no better.”
Despite the promise of the early studies, three recent reviews (1. 2. 3.) suggested that the evidence for acupuncture in depression was inconclusive.
This new study was published in the Journal of Clinical Psychiatry in November of this year and involved 151 patients with Major Depressive Disorder. The study ran for four years. This was a well-conducted clinical trial by researchers who had originally found some promising results in a pilot study (Allen JBJ, Schnyer RN, Hitt SK. The efficacy of acupuncture in the treatment of major depression in women. Psychological Science 1998; 9: 397-401). Although well tolerated, the research failed to support the use of acupuncture as a single therapy for depression.
This is important: depression carries an appreciable mortality and morbidity and there are real ethical problems about withholding treatments that have been shown to work.
It also does not mean that acupuncture has no place in the treatment of depression: it may be a useful adjunctive treatment – particularly if the individual has comorbid anxiety – and it may help with treating the side effects of conventional medicines. There is also another important point: we need to be sure that we are measuring the right thing when doing studies on acupuncture: the Western doctor may want to see if depression gets better. The acupuncturist may be more interested in improving the overall well being of the individual as well as helping an individual’s search for meaning.
Regular readers will remember that last month I commented on some promising research on the use of qigong in depression. Why the different results from the different studies? There are many schools of acupuncture, t’ai chi ch’uan and qigong, as there are many different medicines for depression. One of the difficulties in the critical evaluation of these forms of treatment is that we have to assess the effectiveness not just of acupuncture, but of different schools of acupuncture and sometimes of different practitioners: a daunting but not impossible task. Not only are there many school in China, there are also Japanese, Korean and Vietnamese variants of traditional acupuncture, Western acupuncture and electro- and laser acupuncture. We use clinical observations to guide us to research the most promising types of intervention, whether they are forms of acupuncture, herbal remedies, homeopathy or anything else.
My "job" is to bring you the best and most rigorous research so that you can make decisions about what is most likely to help you.
Blue Light at Night Morning Delight
Do you ever see that episode of the original Star Trek in which Spock is accidentally – and temporarily – blinded when he is exposed to ultra-bright light to drive out a parasite? For people who like to know such things, it was episode 29, entitled Operation: Annihilate!
In the end it turns out that he only needed to have been exposed to one invisible wavelength of light. Naturally enough, being Star Trek it all comes out all right in the end.
I was reminded of this as I examined some extraordinarily important recent research from Thomas Jefferson University in Philadelphia. We have known for a long time that light is an effective treatment for seasonal affective disorder (SAD). However, until now, nobody has been able to determine the best wavelength to use. This new research found that the most effective wavelength was blue. It is thought that blue light therapy may help a great many more things than SAD.
SAD is one of a group of disorders involving our circadian rhythms. Many experts are currently trying to establish the relationship between SAD and another major disturbance of circadian rhythms: bipolar disorder. They are certainly not the same thing, but they are closely related to each other. Some other circadian rhythm disturbances that may respond to blue light are sleep disturbances, jet lag, sleepiness during shift work and spaceflight.
It has always been assumed that the brain’s major pacemaker – the suprachiasmatic nucleus (SCN) – only responded to bright light at a certain time of day. The SCN regulates the production of melatonin by the pineal gland. The fact that lower-intensity blue light is more effective than the most visible kinds of light is part of a body of evidence that there is a separate photoreceptor system within the human eye. The system that resets the body clock to the 24-hour day is different from the rods and cones used in regular vision.
In linked research by the same investigators, as well as a team from and Brigham and Women’s Hospital and Harvard Medical School in Boston, blue light was shown to directly reduce sleepiness. People exposed to blue light were able to sustain a high level of alertness during the night when people usually feel most sleepy. The results suggest that light may be a powerful countermeasure for the negative effects of fatigue for people who work at night.
There is more to this research: breast cancer is linked to fluctuations in human circadian rhythms, with higher rates in industrialized countries where there is a great deal of exposure to artificial light at night. It has been suggested that melatonin may be a link between artificial light and breast cancer. Blue light may perhaps mitigate some of the effects of light on suppressing melatonin.
There is another point to be made here. Many people teach techniques of being able to see the human aura. Many of the techniques of the “See the aura in 30 seconds” type, are no more than visual illusions. But there is another group of techniques that involves the use of peripheral vision to gradually become aware of the fields around people, animals and plants. By a strange “conincidence” the ancients identified the pineal gland with the “third eye.” Have the researchers inadvertently found a biological mechanism for seeing auras?
“Sleeplessness is a desert without vegetation or inhabitants.”
–Jessamyn West (American Writer, 1902-1984)
Exercise and Mood
Most people who exercise on a regular basis soon begin to notice that if they miss a day or two, it will quickly have an effect on their mood and motivation. There’s recently even been some research to confirm it. Many years ago it was shown that one of the mechanisms for the “Runner’s high,” was the production of endorphins and we now have a great deal of research that is revealing the fundamental mechanisms linking exercise and mood.
Though the link between exercise and mood has been recognized for decades, in the last few years we have seen an increasing body of evidence that exercise can have a useful effect on people with mood disorders. The evidence is extensive (For example: 1. 2. 3.) and is now so strong that many clinicians – and certainly all practitioners of Integrated Medicine – routinely recommend physical exercise as part of a package of health care. There is particularly good evidence that exercise will help with some of the less common types of depression. An exercise program may particularly benefit women with progesterone-related premenstrual mood disturbances.
We now have some good evidence about the mechanisms by which exercise can improve mood. Researchers in China did some experimental work in rats with what they called “Chronic unpredictable stress.” It is just what it sounds like. If the little critters keep getting stressed, they develop many of the signs of depression: they show loss of appetite, social withdrawal and a reduction in exploratory behavior. We could say that the repeated stress reduces their resilience. Chronic stress causes dysfunction in the hormonal system that links the hypothalamus and pituitary glands at the base of the brain, with the adrenal glands that are perched atop the kidneys.
The researchers then gave some of the rats the opportunity to exercise on a wheel. The exercising rats had an increase in the amount of a growth factor called brain-derived neurotrophic factor (BDNF) in a key region of the brain called the hippocampus. In the non-exercisers, the levels of the growth factor went down as they experienced more and more stress. Exercise also smoothed out stress-induced rises in the hormone cortisol.
This is particularly interesting because previous research had shown us that exercise can increase BDNF levels in the brains of stressed and unstressed animals. We also know that if an antidepressant is going to work, it has to be able to stimulate the production of BDNF in the hippocampus of the brain.
One thing that has not been much studied is the impact of exercise on sleep architecture. Most exercisers know that a good workout, run or hike can make you sleep like a log. And there is increasing evidence that correcting sleep disturbances can be a most effective way of improving mood. So much so that many of us now believe the sleep disturbances underlie many mood disorders, rather than sleep disturbances being symptoms of sleep disorder.
My conclusion from reading the literature and working with countless individuals is that unless there is a medical contraindication, a combination or weight training and aerobic exercise should be part of the treatment program for anyone with depression. The biggest problem is motivating someone with depression t do something like exercise. Sometimes it is necessary to wait until the primary treatment has taken hold. Though we have often had a great deal of success by using some of the motivational systems that I’ve described in Healing, Meaning and Purpose.
Qigong in the Treatment of Depression
I first started teaching T’ai Chi Ch’uan and qigong over 20 years ago, and I was always impressed by the apparent benefits for people with chronic low mood. Not so much in people with severe depression, but in people who were just chronically miserable.
During a visit to Hong Kong in 2004, I heard about some interesting research that’s just been published. Researchers from the Department of Rehabilitation Sciences at the Hong Kong Polytechnic University and Kwai Chung Hospital, examined the effects of regular qigong in 82 older people with a diagnosis of depression. After just eight weeks of regular daily practice, there was an overall improvement in mood, self-efficacy and personal well-being. By week sixteen there were really quite marked improvements not just in mood, but also in activities of daily living and how people felt about themselves.
We know that there are close links between mood and the immune system, so this research fits in with a study from Tokyo in which a breathing method said to enhance Qi was shown to reduce stress and modulate the function of the immune system.
There are many studies of qigong, but they are of variable quality. Another one which supports both of these two studies comes from Korea, where something slightly different – qigong therapy – was shown to help both pain and mood in older people with chronic pain form a variety of causes.
I do not think that we have enough evidence to try using qigong alone in the treatment of depression, which is, after all, a potentially fatal condition. But I do think that Qigong is an important part of an Integrated Medicine program, and I am creating more resources for people to do the first stages of qigong on their own.
Breathing
“Without mastering breathing, nothing can be mastered.”
–George Gurdjieff (Armenian-born Adept, Teacher and Writer, c.1873-1949)
I strongly recommend breathing. It’s actually one of my favorite pastimes….
Of course breathing is all-important, but it is just as important to ensure that you are breathing in good quality air. Scattered throughout the world are weather fronts accompanied by hot dry winds of ill repute:
- The Santa Ana Winds of Southern California,
- The Mistral of France
- The Khamsin of North Africa
- The Foehn of Switzerland
- The Sharav in Israel
- The Chinook of Canada
- The Sirocco in parts of the Mediterranean
- The Xlokk of Malta
- The Zonda in Argentina
- The Halny of the Carpathian Mountains
These are just some of these winds, that have been known for centuries to precipitate a variety of symptoms in the exposed population, including depression, irritability, insomnia and headaches. The explanation of these effects is an increase in the number of positive ions in the atmosphere, which alter the amount of serotonin in some parts of the brain. I was consulted about an epidemic of headaches amongst people working in an electrically insulated room. It soon became clear that the setup had allowed an enormous concentration of positive ions, and once they installed a negative ionizer virtually all the headaches stopped. We believe that many of the beneficial effects of high altitudes or of being near waterfalls of fountains spring from the way in which they generate large numbers of negative ions.
Poor oxygenation of the lungs has been known for many years to be associated with disease. Pulmonary tuberculosis classically affects the upper lobes of the lung, where there is the poorest oxygenation, and it has been known for a century that people suffering from a blockage of the mitral valve of the heart, which leads to high blood pressure in the lungs, do not get tuberculosis in that part of the lungs.
Conscious control of the breath enables us to modulate the activity of the autonomic nervous system. Specific types of breathing can induce specific psychological and physical effects.
We usually breathe through one nostril at a time. Either the right or left nostril is dominant for anywhere from 45 minutes to two hours. You then switch sides. This is known as the nasal cycle, and is one of the faster circadian rhythms. The popular yogic practice of single nostril breathing is thought to feedback directly into the hypothalamus of the brain. You can learn to use this to your advantage. If you are right handed, if you direct your focus onto opening the right nostril, you may well find an increase in salivation, which is an aid to good digestion. A useful trick that we have used for many years is at bedtime to start by lying on your left side, which has the effect of opening the right nostril, and after ten minutes roll onto your right side for sleep. Again you reverse this if you are left hand dominant. It seems that this simple trick lowers your core temperature, which is one of the main determinants of sleep. There is some research that opening the right nostril increases body temperature, while opening the left has a calming effect. These techniques are often very helpful. Apart from these physical effects, using the breath is one of the quickest ways to learn to sense the subtle forces of the body.
You may already have some breathing practice that you like, and by all means continue using it. If you need a new one, the simplest that I have ever been taught, and that I have used with countless students and patients is this:
Count your breaths. Breathe deeply using your abdominal muscles, so that you are drawing more air into your lungs. Stop immediately if you feel faint or dizzy. As thoughts come up, keep concentrating on the incoming and outgoing breath. Gradually slow the breath, by extending the pause between the inhalation and exhalation.
I always make myself unpopular when I insist that people check with a healthcare provider before stating any exercise plan, including breathing. But I’m going to say it anyway. It just makes good sense!
“Controlled deep breathing helps the body to transform the air we breathe into energy. The stream of energized air produced by properly executed and controlled deep breathing produces a current of inner energy which radiates throughout the entire body and can be channeled to the body areas that need it the most, on demand. It can be used to fuel a specific physical effort, such as tennis or jogging. Or you can use this current of inner energy to relieve muscular tension throughout the body, revitalize a tired mind, or soothe localized aches and pains.”
–Nancy Zi (American-born Chinese Opera Singer, Voice Teacher and Qigong Expert)
DHEA: Hype, Hope and Disappointment
Dehydroepiandrosterone (DHEA) is a hormone that has attracted a lot of attention. It’s launched hundreds of websites, product lines and a few books and magazine articles. So what’s all the fuss about, and should we all be chomping down on DHEA tablets?
DHEA is manufactured at several sites in the body, but by far the most important is in one of the outer layers of the adrenal gland. Like all the steroid hormones it is made from cholesterol. It has various protective effects in the body, regulates some enzyme systems, can be converted to estrogen and under certain circumstances to testosterone. It has very weak androgen (male hormone) activity.
In cell culture it has a lot of other actions too, but it is always difficult to jump from effects seen using large doses in isolated cells, to giving advice on what supplements people should be taking.
There has been a lot of talk about the possibility that some people may, as a result of stress or toxins, suffer from exhaustion of the adrenal glands. There is a great long list of symptoms that may be caused by this so-called adrenal fatigue, deficiency or insufficiency: the terms are often – and incorrectly – used interchangeably. And therein lies the problem. It is such a long list that it is non-specific. It’s always a bit of a worry when someone tells me that dozens of different symptoms are all caused by one single biochemical problem. That just isn’t the way that the human body works.
I have seen and treated countless people with a condition known as Addison’s disease: true chronic adrenal insufficiency. It can be a very serious illness and it is quite different from the “adrenal fatigue” that people talk about in some popular books. People with chronic fatigue syndrome do have lower levels of activity in what is known as the hypothalamic-pituitary-adrenal axis, but it is not because the adrenal glands are not working properly, but because the hypothalamus in the brain is not doing it’s job properly. There’s also no proven link between “burnout” and adrenal function.
During my years as an endocrinologist and holistic physician, I’ve spent a great deal of time looking for adrenal fatigue in sick people and I’ve never found it. I’ve done all the tests recommended by proponents of adrenal fatigue and adrenal insufficiency and when we’ve done the tests properly, we’ve drawn a blank. There are a great many parallels between the adrenal insufficiency story, and the old – and discredited – myth about people becoming unwell because of a thyroid deficiency that cannot be picked up on standard thyroid function tests.
So can DHEA do you any good? Or can it be harmful? What exactly is the evidence?
- There is a comprehensive study, called The Dehydroepiandrosterone And WellNess (DAWN) study that should give us some solid answers as to the risks and benefits of DHEA. I shall post details of the findings as they become available. But some things we know already:
- DHEA has been touted as an anti-aging supplement. But in a two-year prospective study done in older people attending the Mayo Clinic in Rochester, Minnesota, neither DHEA nor low-dose testosterone replacement had physiologically relevant beneficial effects on body composition, physical performance, insulin sensitivity, or quality of life. Perhaps the people in the study didn’t get enough DHEA, but it doesn’t look that way. Instead it seems that just giving the supplement doesn’t seem to do very much. But there is increasing evidence that 50-100mg of DHEA each day will improve muscle strength and muscle mass in older people who are doing strength training. Once again, it does nothing in people who are not exercising. Sorry!
- According to the results of a small placebo-controlled, randomized trial published in the Archives of General Psychiatry, DHEA can be effective for midlife-onset minor and major depression. The study was conducted the National Institute of Mental Health Midlife Outpatient Clinic. In the trial, 23 men and 23 women aged 45 to 65 years with midlife-onset major or minor depression were randomized to six weeks of DHEA therapy, 90 mg/day, for three weeks and 450 mg/day for three weeks or to six weeks of placebo followed by six weeks of the other treatment. The subjects did not receive any other antidepressant medications during the study. Both of the doses of DHEA helped improve depression: there was no advantage in going to a higher dose, and there was no difference in the treatment response of men and women. The trouble with this study was not just the small size and the short duration, but the DHEA was not compared against a standard antidepressant. So we are still in the dark as to how effective it really is. It’s nice that it’s better than placebo, but this is just the first step in a larger research program.
- A study from Taiwan indicated that people with higher levels of DHEA sulfate had a lower overall mortality over a three-year period. That is interesting, but absolutely does NOT mean that artificially increasing our levels of DHEA with supplements will make us live forever: we don’t yet have that kind of magic bullet.
- In mice, quite large amounts of DHEA have the effect of slightly reducing the normal increase in stiffness of the left ventricle that can happen as animals get older. We have no idea whether something similar might help in humans, and the amounts of DHEA involved may rule it out as a viable treatment in people.
- 50mg/day improves subjective wellness in people who have no active pituitary gland. A rare condition, and we cannot use this evidence to advise healthy people about what to take.
- Because DHEA is converted into estrogen and/or testosterone, it may have the potential to exacerbate or initiate hormone-responsive tumors. The evidence is not strong one way or the other, but it remains a worry. I don’t think that anyone recommends DHEA to people who have a personal or family history of breast or prostate cancer.
There is a BIG literature on DHEA. But my current conclusions from all this?
- 50-100mg of DHEA is probably worth trying if you are over 50 years of age and doing regular exercise.
- It may help a bit with mild depression.
- It should not be used in people with a personal or family history of breast, prostate or any other type of hormone-sensitive cancer.
Pramipexole
Pramipexole is a remarkably interesting medicine about which you are likely to hear a lot in the near future. It is an agonist, which means that it has a positive effect, on D2 dopamine receptors and also on a little-known group of dopamine receptors, known as the D3 group. If you want to get really clever the dopamine receptor D3 group is abbreviated to DRD3. Pramipexole has been in use for almost a decade in the treatment of Parkinson’s disease, and approximately 9.1 million prescriptions for pramipexole have been written in the U.S. since its launch in 1997. It is not without its problems. In Parkinson’s disease it may cause dizziness, involuntary movement, hallucinations, headache, difficulty falling asleep, sleepiness, and nausea. Some people have also had behavioral dyscontrol while taking it.
At a meeting in Athens in February of 2006, we saw confirmation of something that had been shown in previous research: pramipexole seems to be a very effective treatment for restless legs syndrome (RLS). A study published in the journal Neurology has given us a more detailed understanding of the risks and benefits of pramipexole.
The investigators report a 12-week, multicenter, double-blind, randomized, placebo-controlled study of fixed daily doses of pramipexole (0.25 mg, 0.50 mg, and 0.75 mg) involving 344 patients with moderate to severe RLS. Data from 339 patients were analyzed to evaluate the effect of pramipexole treatment on efficacy and safety. The mean age of patients was 51.4 years and the mean duration of RLS symptoms was 5.1 years. The results were very promising, even though half of the patients on placebo also showed an improvement. The most commonly reported side effect included nausea (19.0%), headache (17.8%), insomnia (10.5%) and somnolence (10.1%).
In Europe pramipexole it has been approved for use in this indication. It is marketed as Sifrol® / Mirapexin® In the United States we currently only have one approved medical treatment for RLS, and that is the GlaxoSmithKline medicine ropinirole (Requip), that works at the same D3 receptors in the brain and spinal cord. Ropinirole is effective in a proportion of people with RLS, but it has also been linked to sleepiness, drops in blood pressure and fainting, so those are included in its label.
RLS may be associated with some other illnesses so I was very interested to see two reports of the use of pramipexole in bipolar depression as well as a report of its possible use in REM Behavior Sleep Disorder.
One of the most exciting potential uses for pramipexole may be in some people with fibromyalgia. I’ve mentioned that fibromyalgia, bipolar disorder and some other psychiatric illnesses may be connected. The idea that we might be able to use just one medicine to support our Integrated Medicine approach is very attractive, and also helps point us toward a deeper understanding of what exactly goes wrong at the physical level in RLS, depression and fibromyalgia.
I’ll keep you posted.
Psychiatric Illnesses and Fibromyalgia
There’s an interesting and important article in last month’s issue of the Journal of Clinical Psychiatry, by a group of investigators from the University of Cincinnati.
They have shed important new light on fibromyalgia. We’ve recently learned how it is linked to disturbances of the serotonin transporter, as well as anti-inflammatory proteins, and that is may respond best to the kind of comprehensive multi-leveled approaches that we use in Integrated Medicine.
The new research compared people with fibromyalgia with people with rheumatoid arthritis, and it found that fibromyalgia, but not rheumatoid, may be associated with a range of psychiatric illnesses:
- Major depressive disorder
- Bipolar disorder
- Comorbid anxiety disorders including panic disorder, social phobia, posttraumatic stress disorder and obsessive-compulsive disorder
- Eating disorders and
- Substance abuse
What was particularly important in this study was that the psychiatric problems usually preceded the onset of fibromyalgia. So it wasn’t that people were developing psychological problems because they were in chronic pain.
It’s beginning to look as if fibromyalgia is part of a larger group of disorders that all share common etiologies or causes. Family studies have indicated that fibromyalgia and mood disorders share some of the same – perhaps genetic – determinants.
The study also confirms what we have said before: fibromyalgia is not only associated with some psychiatric problems, but also with other medical disorders, several of which may also co-exist with the same psychiatric problems. They include:
- Chronic fatigue syndrome
- Irritable bowel syndrome
- Interstitial cystitis
- Multiple chemical sensitivities and
- Migraine
Not only does this research highlight the need to check people with fibromyalgia to see if they might also be struggling with a psychiatric problem, but it is helping us home in on some of the mechanisms linking these apparently separate problems.
This particular study was done mainly in white women, and the investigators knew who had fibromyalgia, so there’s more work to be done.
But if you or a loved one is struggling with fibromyalgia, it is good news to know that we are making rapid progress in unraveling this horrible illness.
Artificial Light and the Biological Clock
Many of the things that we do to babies and young children have been called into question in recent years.
The debate about doing an excessive number of fetal ultrasounds and high tone deafness seems to have gone away for now. Though not disappeared: there is a paper in the week’s Proceedings of the National Academy of Sciences that revisits this important issue. Then there was the realization that doctors were not good at recognizing and dealing with pain in very young children.
And now there is another one that has worried me for years: what happens to babies who are exposed to constant high levels of light? Doesn’t it damage the development of normal circadian rhythms?
I have just seen a study that seems to confirm some of those fears.
Investigators from Vanderbilt University in Nashville examined the impact of exposing babt mice to constant light. The main biological clock is in the brain, and is located in a region called the suprachiasmatic nuclei (SCN). It is responsible for orchestrating an orderly internal physiological and behavioral cycle. It influences the activity of virtually all our organs, including the brain, heart, liver and lungs. It egulates the daily activity cycles that we call circadian rhythms.
When the mice are exposed to normal variations in light the cells of the SCN quickly become synchronized, and a normal circadian rhythm is established. Constant exposure to light disrupted the development of the SCN and prevented the animals from developing normal circadian rhythms.
This is far from being an academic exercise: each year around 14 million premature babies are born worldwide, and many are exposed to artificial lighting in hospitals. If their biological clocks are not allowed to develop normally, we would anticipate that they would, in later life, have less psychological resilience, and to be prediposed to sleep and mood disorders.
I could conceive of a way to test that experimentally by looking at records of people wth those problems. Secondly, we need to see if reducing unnecessary light exposure would have a real benefit for babies, and for the children and audlts that they will become. I would be astonished if exposing babies to a natural spectrum of light and a natural light cycle did not have enormous benefits for them as they grow up.
