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.
Acupuncture, Qigong and Fibromyalgia
As we have discussed before fibromyalgia can be difficult to treat, so any decent research indicating a new approach is always welcome.
Two recent studies have indicated that acupuncture may be helpful in the treatment of fibromyalgia. In the first, published in Alternative Therapies in Health and Medicine, 21 patients completed the study, which consisted of 16 treatments in eight weeks. The patients all know that they were getting acupuncture, and there was no attempt to “blind” the study. The investigators used something called the Fibromyalgia Impact Questionnaire, and found an improvement. One of the problems with the study was that there were so many measurements done in so few people that there’s always a worry that something positive will turn up by chance. This may explain an odd observation: sicker people did better and it didn’t matter how long they had been in treatment.
The second study was a partially blinded, controlled, randomized clinical trial of 25 patients and 25 controls done at the Mayo Clinic. Acupuncture seemed to be more effective in improving pain, fatigue and anxiety, than putting needles at ineffective points.
One of the biggest practical problems is that some people with fibromyalgia are so sensitive that they cannot tolerate even the mild discomfort of acupuncture, which is usually all but painless if done by an expert.
So I was interested to see a small pilot study from the Department of Psychiatry in the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School in Piscataway, New Jersey, of the use of external qigong in fibromyalgia. A qigong practitioner worked to stimulate the flow of Qi in people with fibromyalgia, on the principle that in traditional Chinese medicine, pain is usually conceived as a blockage of the free flow of Qi. The results were very strongly positive, thought the trial only involved ten people.
Clearly more research is needed, but these preliminary results are all very encouraging.
Hostility and Insulin Resistance
Insulin resistance – a reduction in the body’s ability to respond to insulin – is something that should interest and concern all of us. Not only are a third of Americans insulin resistant, with much higher rates in people of African and Indian heritage, but also insulin resistance is the major predictor of the development of type 2 diabetes and of coronary artery disease.
We already knew that stress and certain personality factors, including hostility can be associated with insulin resistance. Now new research from The Cleveland Clinic in Ohio has clarified the association.
The study involved 643 men with an average age of 63.1 years, and the findings are published in the current issue of Psychosomatic Medicine.
The researchers measured the subjects’ urine levels of norepinephrine. Norepinephrine is one of the objective indicators of stress. The researchers used standard rating scale – the Minnesota Multiphasic Personality Inventory and the Cook-Medley Hostility scale – to measure hostility. Insulin resistance was measured using some highly validated methods: the homeostatic model assessment index; 2-hour post-challenge glucose and insulin levels. The study had to be large because some many things can influence insulin resistance: nine other common variables had to be factored in to the analysis.
The study found that there was a statistical interaction between hostility and stress level in predicting insulin resistance. More hostile people do not always have worse insulin resistance, but they do when they are under stress, particularly if it is high level and sustained stress.
The team also found that not all components of hostility are related to insulin resistance. For instance, cynicism is a personality trait that is strongly related to insulin resistance.
We do not know if stress management techniques can reduce the risk of developing insulin resistance in these high-risk people, but it is likely that they will.
Yoga, tai chi ch’uan, meditation, psychotherapy may all be helpful. The best results of all have been to combine one or other of these with homeopathy, flower essences and spiritual counseling. We have little empirical research for these combined approaches, but a great deal of clinical experience that they may be beneficial.
If you notice that you or someone around you has a hostile, cynical way of handling stress, let them know that they are at high risk of developing a physical illness, but that there is a great deal that they can do for themselves before they fall off the cliff.
The Vagal Path to Compassion
Students of biology or medicine will likely be familiar with one of the largest single nerves in the body, called the vagus or “wandering” nerve. The nerve emerges from the brainstem and is one of the most important contributors to the parasympathetic nervous system, having important effects on the heart, lungs and intestines. The vagus causes the heart to slow, the intestines and kidneys to become more active and the bronchi to constrict. The vagus also has profound effects on metabolism: it has been known for more than a century that stimulating the base of the brain with opiates can cause the release of glucose from the liver, an effect mediated by the vagus. The nerve is also involved in the interaction of the immune system and the brain.
In recent years a technique called vagus nerve stimulation has been found to help some people with intractable epilepsy or treatment resistant depression. Many of the techniques of yogic or Taoist breathing as well as some techniques for inducing altered states of consciousness by eye movements or stimulating specific points on the ears all revolve around vagal stimulation. Some of these techniques have been shown to produce a sustained reduction in blood pressure.
I would like to focus upon the effects of the vagus on the heart. The heart is a physical location of an aspect of our emotional functioning. In Chinese Medicine it is known as the repository of Shen or Spirit. The heart is more than just a pump. It is also an important endocrine gland, and there is some evidence that it is also a sensory organ, with a sophisticated system for receiving and processing information. The neural network within the heart enables it to learn and remember. The heart constantly communicates with the brain, influencing key areas involved in perception, cognition and emotional processing.
You or someone you know may have had a baby. In which case you or they will have had intrauterine cardiac monitoring. Normally the baby’s heart rate varies from minute to minute. Some forty years ago it was discovered that if that variation stopped, it could be a harbinger of doom. Obstetricians knew this, but the rest of medicine forgot about the observation until 1991. Since then there has been enormous interest in the phenomenon of heart rate variability (HRV), because if it is lost, it can be a potent predictor of health problems. HRV reflects the tone in the autonomic nervous system. If this system becomes unbalanced, it can have effects on most of the major organs.
In the Ageless Wisdom the vagus is called our psychic antenna. We all have one, but not all of us have relearned how to use it. Many psychic stressors can produce physical effects via the vagus nerve. When doing acupuncture or energy healing it is very common for the patient to get a slowing of their heart rate and abdominal rumblings, which are sure signs of vagal activity. Psychics often get problems with their intestines while working with people, not from upset, but because they are exercising their skills.
There has been some interesting speculations about the role of the vagus in social behavior. Researchers have found
that children with high levels of vagal activity are more resilient,
can better handle stress, and get along better with peers than children
with lower vagal tone.
There is a project underway at the University of California at Berkeley to see whether the vagus nerve might be the seat of compassion. Dacher Keltner is a professor of psychology and coeditor of Greater Good, a magazine about prosocial behaviors such as compassion and forgiveness. He has been examining the novel hypothesis that the vagus nerve is related to prosocial behavior such as caring for others and connecting with other people.
In his laboratory, Keltner has found that the level of activity in people’s vagus nerve correlates with how warm and friendly they are to other people. Interestingly, it also correlates with how likely they are to report having had a spiritual experience during a six-month follow-up period. Vagal tone is correlated with how much compassion people feel when they are presented with slides showing people in distress, such as starving children or people who are wincing or have a look of suffering on their faces.
Perhaps a key to compassion is to be found in the heart and the face.
Compassion is crucial to our survival. But compassion leavened with wisdom.
“Love and compassion are necessities, not luxuries. Without them humanity cannot survive.”
–The 14th Dalai Llama (a.k.a. Tenzin Gyatso, Tibetan Religious and Political Leader, 1935-)
“Out of compassion I destroy the darkness of their ignorance. From within them I light the lamp of wisdom and dispel all darkness from their lives."
–Bhagavad Gita
Music Therapy
Music therapy has been in use for millennia: in the Bible David played his harp to try to ease the suffering of King Saul and there are whole systems of musical healing in the traditional healing systems of China and India. I have commented before on the extraordinary power of music.
Apart from our experience, there is an astonishingly large and diverse body of scientific literature on music therapy, not just to help individuals, but also on possibly improving the performance of health care providers. Many surgeons attest that they do a better technical job if they are listening to music.
This month’s issue of the British Journal of Psychiatry carries an interesting article about the value of music therapy in people with schizophrenic illnesses. Though small, it indicates that music therapy can be helpful, and speaks to the integrity of many components of the nervous systems of people with this large and diverse group of problems.
There is good evidence that music therapy may help with:
- Treatment-related distress in people having treatment for several cancers
- Autistic spectrum disorders
- Calming people who are having cardiac catheterization procedures
- Pain relief
- Distress after total knee replacement
- Pain after leg fractures
- Apathy in people with dementia
- Sleep and heart rate patterns in pre-term babies
This is by no means an exhaustive list: I have found several hundred studies, many of which are quite well designed. There are also several professional organizations such as the American Music Therapy Association.
It is clearly important to choose the right kind of music: I would guess that Metallica is less likely to soothe the fevered brow than Steve Halpern.
Background music can be wonderful for improving the ambience of your home or workplace. But you can also be more focused in your use of music to help or support other types of health and wellness programs.
Select the music that you like: there are now many wonderful programs geared toward using music for healing: I can give you a list of some that I have tested. The good ones will entrain your heart rate, some of your brain rhythms and the subtle systems of your body.
If you can find 20 minutes, the right music listened to while sitting or lying with your eyes closed can be as effective as a short meditation. For this to work well, it is best to use good quality headphones and to allow the music to wash over and soak you like a warm bath, while gradually slowing and deepening your breath.
I’ve also made extensive use of specifically chosen music during massage, acupuncture, yoga, and while practicing t’ai chi ch’uan and qigong. Some purists don’t like using music while doing these activities, but I’ve usually found that music can enhance each type of practice.
Try it and see what you think.
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.
Acupuncture Points
The Pacific College of Oriental Medicine publishes a newspaper entitled Oriental Medicine, that carries a great many interesting articles mainly written by practicing acupuncturists. In the current issue there is a nice article entitled “What are Meridians and Points?” by Iona Marsaa Teeguarden a therapist who has developed some very interesting acupressure techniques for dealing with an array of problems. This is a very interesting topic to me: you may have seen some of those pictures of acupuncture points that look like tramlines traversing the body.
Over the last few years I’ve read everything about the acupuncture points that I could get my hands on. If it’s in one of the ten or twelve languages that I can read, then I’ve probably got a reprint of the paper, and people have been kind enough to send me translations of at least parts of papers in Chinese, Japanese and Korean. Some of the research has been excellent, and some less so.
The first point (ha ha…), often controversial when I am talking to classically trained acupuncturists, is that although some of the large well-known acupuncture points are usually in the same place in different individuals, many of the lesser known points are not. Of the 361 main named acupuncture points only a couple of dozen seem to be fixed on the body. Most of the rest can be some way off from the pictures in books. I learned that first when I was an apprentice in London, and then during my studies in China. The top Chinese acupuncturists search for the right points to use. It’s one of the reasons why modern Chinese acupuncturists have identified over a thousand “extra points.”
Although people usually talk about “meridians” joining the acupuncture points together, the Chinese usually refer to them as “channels and collaterals.”
There does not seem to be any neurological or vascular structure at the site of an acupuncture point. Taken together with he fact that acupuncture points tend to be tender and to have characteristic electrical properties, both of which get better with treatment, suggests that they are functional rather than structural entities. Most experienced acupuncturists have noticed that the points vary not just with treatment, but also with mood, the weather and in women, during the menstrual cycle.
In the late 1930s, a French physician named Niboyet was probably the first to find indications that the main acupuncture points have lowered electrical resistance compared with surrounding skin. Some other studies (1, 2, 3, 4, 5.)have provided some support for these findings, although it is difficult to known precisely what to make of the finding that these areas of reduced electrical resistance can also be located on fresh but not dried cadavers. Some people have invoked some mechanism involving electrolytic fluxes along connective tissue or fascial planes of the body. But that’s all just speculation backed by some research correlating acupuncture points and fascial planes.
An additional problem for simple electrical models is that some of the acupuncture points also respond to polarized light, which would be odd if the primary mechanisms of acupuncture points were electrical.
Another set of experiments sought to exploit the phenomenon of “propagated needle sensation.” If acupuncture is done well, then this happens very frequently. It is a subjective sensation of warmth, heaviness, numbness or bursting, that moves at between 1 and 10 centimeters per second, which is much slower than a nerve impulse. This sensation moves along the proposed channels along which the Qi is supposed to flow. But this is the interesting bit: the sensations are not related to any known neurological pathways. The precise nature of this propagated needle sensation remains elusive, with reports of it being interrupted by chilling, local anesthetics and mechanical pressure, whilst it has also been shown to travel to phantom limbs in amputees.
Attempts have been made to trace out acupuncture points and their associated channels by the use of radioactive tracers and by measuring electrical propagation along the channels. 99-Technetium has been the most widely used, and it has been claimed that the tracers diffuse from acupuncture points along the classical acupuncture channels, whilst tracer injected at non acupuncture points diffuses without showing any such linear pattern. The speed of the linear migration of the tracer injected into acupuncture points was accelerated by the use stimulation of appropriate acupuncture points.
If we cannot find anything anatomical at acupuncture points, and they clearly change place and character as the person changes. Then what do the Chinese have to say about the points and the channels?
They say that the channels are there to distribute Qi, and that the acupuncture points are the control points of the channels. The traditional theory is that Qi flows in response to thoughts and emotions. Perhaps thoughts and emotions have effects on muscle contraction and that pushes the Qi along, but I thin that we have to step away from the physical body. I can well remember one of the first people whom I ever treated. I gently needled a “Liver point” on her foot, and she felt the sensation in her eye on the same side of the body. There is no known neurological connection between the foot and the eye on the same side. But in Chinese medicine, the Liver channel terminates in the eye on the same side of the body. The theory of fascial planes can also not explain that. Neither can the observation that many of us have made in the clinic. In some people, acupuncture reveals their entire acupuncture system: the channels become red.
Even when acupressure is used in the subtle systems around the body. I have seen a Chinese Qigong Master demonstrate this phenomenon in a paraplegic patient.
While the Master’s hands were three feet away for the body.
And that will be the topic of yet another research study.
T'ai Chi Ch'uan and Health
I have written about some of the research into the health benefits of T’ai Chi and Qigong.
I was very pleased to see that this month’s issue of T’ai Chi: the International Magazine of T’ai Chi Ch’uan dedicated several pages to some of the research that is being done on the field and advised practitioners to participate in local research projects.
It was that last piece of advice that I particularly liked.
The article by Charlotte Jones, a Chen Style practitioner from Houston, is not a critical review of the literature, and neither is it supposed to be. It lists some of the key findings from studies on balance, osteoporosis, pain and arthritis, blood pressure and cardiovascular health without going through their pros and cons.
But a short list like this is a good jumping off point if you are starting to look into learning T’ai Chi and would like to know some of the possible benefits.
I shall also continue to provide you with more critical reviews of studies as they come out.
Happy World Tai Chi & Qigong Day!
Saturday, April 29, 2006 is World Tai Chi & Qigong Day . The day is going to be celebrated in 60 countries around the world as well as all fifty states. The event has been recognized by the United Nations World Health Organization, and proclaimed officially for 17 US states by their governors, as well as senates, legislatures and mayors of various countries.
I taught Tai Chi and Qigong for several years, and had the privilege of studying with teachers in China and Malaysia whose methods were part of an oral tradition. Much of this material has still not been published. I recently reviewed a very nice book at the Amazon.com website. One of the things that impressed me about the book is that it contained exercises and techniques that I had been taught by Chinese Masters, but which to my knowledge have never been published anywhere else.
I thought that it might be a good moment to review the world literature on the medical effects of Tai Chi and Qigong. My search has turned up over 2,200 published reports, of which about a third are the reports of clinical trials. I have been able to analyze the data in about a half of those trials. The data now suggests that Tai Chi is genuinely useful for:
- Preventing falls in the elderly
- Improving functional mobility and some aspects of immune function
- Improving blood pressure and lipid profiles and subjective wellness
- Improving overall physical performance
- Stress reduction in HIV positive individuals
There are many other studies indicating the value of Tai Chi, but these give you a sense of some of the research that is going on at the moment.
As I mentioned in another post, qigong is both a personal practice and is used as a form of therapy. It has recently been shown to help:
- Chronic pain
- Cardiac rehabilitation in the elderly
- Chronic fatigue syndrome
- Overall immune function
- Asthma
This is by no means a comprehensive list, but as you can see, this is an active area of research.
Learning some Tai Chi and Qigong could be one of the best investments that you ever make in your own health.
Technorati Tags: Tai Chi, Qigong, Wellness, Asthma, Chronic fatigue, HIV
Thoughts on Qi
The essential idea that there is some subtle force or "energy" associated with the body is very ancient, and was discussed in India where one form of it was known as prana. Yet there are many types of prana, and there are other forces and energies of increasing degrees of sophistication. The most comprehensive investigations of subtle fields took place – and continue to be explored to this day -in China and Japan, where they have been known as Qi, Chi or Ki. Yet many other cultures also described something similar. Indeed paintings of the Christian saints with golden halos has been thought to be an interpretation of a highly developed subtle energy system. The subtle systems appear to be the bridge between the physical and spiritual worlds.
My book Healing, Meaning and Purpose makes the point that this idea of subtle systems is not some quaint notion belonging to an era of folk medicine and superstition, but is instead a vibrant area of academic research.
Some years ago, before I had started visiting China, I asked the apparently naive question: "What underlies Qi?" I was told that the question was meaningless, because Qi is everywhere and in everything. But I was not so sure, and so began the development of the concept of an "Informational Matrix," that permeates and animates the Universe. Over the years I discussed this concept in great detail with dozens of scientists, intuitives, and then some of the finest acupuncturists and qigong masters in China, Hong Kong, Taiwan, Malaysia, Korea, Japan, as well as in the United States in Europe. I discovered that many people had similar evidence for this underlying principle. And this fundamental animating force has also had many other names: the Inner Light, Mind, Love and God.
I have posted an extract from my book on my website. If you choose to read it, let me suggest leaving all of your current knowledge and beliefs at the door. You can pick them up again on your way out!
With any luck, you will never again look at things in quite the same way.
Enjoy!
Technorati tags: Qi, chi, Inner light, subtle energy
