Emotional health

Two recent reviews found that acupuncture was similar in effectiveness to anti-depressant medication.

Depression

Depression is a common mental health problem that affects people of all genders, ages, and backgrounds. About two thirds of adults will at some time experience depression severe enough to interfere with their normal activities (Mintel/YouGov, 2006, Stewart et al, 2004).

Women are twice as likely as men to become depressed (Stewart et al, 2004) partly due to hormone changes occurring pre-menstrually, at menopause, during pregnancy or after childbirth. Depression is estimated to cost the UK £7.5 billion a year in medication, benefits and lost working days (McCrone et al, 2008). The World Health Organization predicts that by 2020 depression will be second only to chronic heart disease as an international health burden (WHO, 2008)

Although everyone occasionally experiences low mood, these feelings usually pass after a couple of days. When a person has clinical depression, these problems can become chronic or recurrent, interfering with daily life. Depression causes symptoms such as low mood, loss of interest in enjoyable activities, anxiety, irritability low self-esteem, disturbed sleep or appetite, weight change, tiredness, lack of motivation, concentration or libido, physical pain, and suicidal thoughts.

Depression is likely to result from a combination of genetic, biochemical, environmental, and psychological factors. It may be triggered by stressful events, such as bereavement, illness, relationship problems or financial difficulties.

References

Mintel/YouGov. Depression poll commissioned by the British Association for Counselling and Psychotherapy. 2006 Apr.

Stewart DE, Gucciardi E, Grace SL; Depression. BMC Women’s Health. 2004 Aug 25;4 Suppl 1:S19.

McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton-Smith S. Paying the Price: The cost of mental health care in England to 2026. The King’s Fund, May 2008, ISBN 978 1 85717 571 4.

World Health Organization. 2008. http://www.who.int/mental_health/management/depression/definition/en/

How acupuncture can help

Most research on acupuncture for depression has been carried out in China with Western drugs as comparators. Two recent systematic reviews, both drawing on Western and Chinese data, found that acupuncture was similar in effectiveness to anti-depressant medication and not significantly better than sham acupuncture or waiting list controls. However, they reached very different conclusions, one recommending acupuncture (Zhang 2010) and one stating that the evidence was insufficient (Smith 2010). Major issues to consider in respect of the research evidence are a) how trustworthy are Chinese studies (Ernst 2010), b) how valid are sham controlled trials (Schroer 2010), and c) how relevant to normal practice is the acupuncture provided in trials (Schroer 2010). Notions about acupuncture’s placebo properties (Ernst 2010) can only be speculative, and with little relevance to decisions about patient benefit. Given that acupuncture appears to be at least as effective as existing conventional drugs, without their level of side effects, it should be considered as one of the therapeutic options, alongside the existing repertoire. Two specific situations, during pregnancy (Manber 2010) and post-stroke (Zhang 2010; Smith 2010), seem to be particularly favourable for incorporating acupuncture treatment. (See table overleaf)

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional wellbeing.

Studies indicate that acupuncture can have a specific positive effect on depression by altering the brain’s mood chemistry, increasing production of serotonin (Sprott 1998) and endorphins (Wang 2010). Acupuncture may also benefit depression by acting through other neurochemical pathways, including those involving dopamine (Scott 1997), noradrenaline (Han 1986), cortisol (Han 2004) and neuropeptide Y (Pohl 2002).

Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain which is responsible for anxiety and worry (Hui 2010). Stress-induced changes in behaviour and biochemistry may be reversed (Kim 2009).

Some of the most recent research suggests that depression is associated with dysfunction in the way that parts of the resting brain interact with each other (Broyd 2008); acupuncture has been shown to be capable of changing the ‘default mode network’ (Dhond 2007), but the effect goes beyond that of expectation/placebo (Hui 2010).

Acupuncture can be safely combined with conventional medical treatments such as anti-depressants, helping to reduce their side effects and enhance their beneficial effects (Zhang 2007).

Acupuncture treatment can also help resolve physical ailments such as chronic pain (Zhao 2008), which may be a contributing cause of depression. In addition to offering acupuncture and related therapies, acupuncturists will often make suggestions as to dietary and other lifestyle changes that may be helpful in overcoming depression. Finally, people struggling to cope with depression usually find that coming to see a supportive therapist on a regular basis is helpful in itself.

Anxiety disorders

Accurate information about the incidence and prevalence of anxiety disorders is difficult to obtain; a survey by the Office of National Statistics (ONS 2000) found that 164 people per 1,000 had a neurotic disorder in the week before interview, which represents about 1 in 6 of all adults. They found that the most prevalent neurotic disorder among the population as a whole was mixed anxiety and depressive disorder (88 people per 1,000).

Anxiety disorders include generalised anxiety disorder, panic disorder, phobias, obsessive compulsive disorder (OCD) and post traumatic stress disorder (NICE 2007; Clinical Evidence 2007). They can be chronic and cause considerable distress and disability; if left untreated, are costly to both the individual and society (NICE 2007). As well as emotional symptoms such as worry, disturbed sleep, irritability and poor concentration, anxiety can cause physical symptoms such as sweating, nausea, diarrhoea, dry mouth, palpitations, shortness of breath, dizziness, cold hands, muscle tension and aches, trembling and twitching (American Psychiatric Association, 2000; WHO 2007). Also, the symptoms of many physical conditions can become worse with stress, for example, irritable bowel syndrome, migraines and tension headaches, and back pain (Clinical Evidence 2007).

Treatments recognised as useful for anxiety disorders include psychological therapies such as cognitive behavioural therapy (CBT) and applied relaxation, and medication such as some antidepressants and benzodiazepines (NICE 2007). All the drug treatments have side effects, and many may cause withdrawal or discontinuation symptoms (British National Formulary 2009).

References

American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision). Washington DC: American Psychiatric Association.

National Institute for Health and Clinical Excellence, 2007. Quick reference guide (amended) Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical Guideline 22 (amended) [online]. Available: http://guidance.nice.org.uk/CG22/QuickRefGuide/pdf/English

Office of National Statistics 2000. Psychiatric Morbidity among Adults living in Private Households. [online] Available: http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf

World Health Organization 2007. International Statistical Classification of Disease 10th revision (ICD-10) [online]. Available: http://apps.who.int/classifications/apps/icd/icd10online/

How acupuncture can help

The best evidence for acupuncture’s effectiveness (Pikington 2010; Pilkington 2007) comes in specific acute anxiety situations such as around medical operations (Mora 2007; Wang 2007; Gioia 2006) or dentistry (Karst 2007).

There is surprisingly little research with a primary focus on acupuncture for generalised anxiety disorder. Those studies published so far are mostly small and methodologically flawed, hence the reluctance of reviewers to draw conclusions (Pilkington 2010; Pilkington 2007).

There are also preliminary positive findings for treating chronic anxiety associated with post-traumatic stress disorder (Hollifield 2007), substance misuse (Chae 2008; Courbasson 2007; Grusser 2005), eating disorders (Fogarty 2010), hyperventilation (Gibson 2007), asthma (Scheewe 2008), insomnia (Nordio 2008), post-stroke ((Wu 2008), musculo-skeletal pain (Hansson 2007; He 2005) and various other conditions where anxiety has been measured as a secondary rather than primary outcome.

Although the overall evidence is patchy, it does lie promisingly in a positive direction, and, given the very low level of side effects and lack of demonstrably superior outcomes from other interventions, acupuncture could be considered as one possible therapeutic option alongside the existing repertoire. (See table overleaf).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically benefit anxiety disorders and symptoms of anxiety by:

  • Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010).
  • Regulating levels of neurotransmitters (or their modulators) and hormones such as serotonin, noradrenaline, dopamine, GABA, neuropeptide Y and ACTH; hence altering the brain’s mood chemistry to help to combat negative affective states (Lee 2009; Samuels 2008; Zhou 2008; Yuan 2007).
  • Stimulating production of endogenous opioids that affect the autonomic nervous system (Arranz 2007). Stress activates the sympathetic nervous system, while acupuncture can activate the opposing parasympathetic nervous system, which initiates the relaxation response.
  • Reversing pathological changes in levels of inflammatory cytokines that are associated with anxiety (Arranz 2007)
  • Reversing stress-induced changes in behaviour and biochemistry (Kim 2009).

Acupuncture can be safely combined with conventional treatments such as medication or psycho-educational therapy, possibly enhancing their beneficial effects (Courbasson 2007) and reducing unwanted side-effects (Yuan 2007).

Chronic fatigue syndrome

Chronic fatigue syndrome is characterised by severe, disabling fatigue, and other symptoms such as musculoskeletal pain, sleep disturbance, impaired concentration and headaches (Reid 2007).

The prevalence of chronic fatigue syndrome has been estimated to be from 0.007% to 2.8% in the general adult population, and from 0.006% to 3.0% in primary care, depending on the criteria used (Afari 2003). Chronic fatigue syndrome imposes substantial economic costs on society, mainly in terms of informal care costs and lost employment (McCrone 2003).

The cause of the syndrome remains poorly understood, but hypotheses include endocrine and immunological abnormalities, autonomic nervous system dysfunction, abnormal pain processing and certain infectious illnesses, such as Epstein-Barr virus and viral meningitis (Gur 2008, White 2001). People who have had a prior psychiatric disorder are nearly three times more likely to have chronic fatigue syndrome later in life than those who have not (Harvey 2008).

Prognosis is poor, with only around 5% of adults returning to pre-syndrome levels of functioning (Cairns 2005). Aims of treatment are to reduce levels of fatigue and associated symptoms, to increase levels of activity, and to improve quality of life. Conventional approaches include graded exercise therapy, cognitive behavioural therapy (CBT) and antidepressant drugs (DTB 2001).

References

Afari N, Buchwald D. Chronic fatigue syndrome: a review. Am J Psychiatry 2003;160:221-36.
Cairns R, Hotopf M. A systematic review describing the prognosis of chronic fatigue syndrome. Occup Med (Oxford) 2005;55:20-31.
Gur A. Oktayoglu P. Central nervous system abnormalities in fibromyalgia and chronic fatigue syndrome: New concepts in treatment. Current Pharmaceutical Design 2008; 14: 1274-94.
Harvey SB et al. The relationship between prior psychiatric disorder and chronic fatigue: evidence from a national birth cohort study. Psychol Med 2008;38:933-40.
Reid S et al. Chronic fatigue syndrome. BMJ Clinical Evidence. Search date September 2007.
What to do about medically unexplained symptoms. DTB 2001; 39: 5-8.
White P et al. Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis. Lancet 2001;358:1946-54.
McCrone P et al. The economic cost of chronic fatigue and chronic syndrome in UK primary care. Psychological Medicine 2003; 33: 253-61.

How acupuncture can help

There are consistent positive results from observational studies (Wang 2008, Huang 2008, Guo 2007), but very few randomised controlled trials as yet (Wang 2009a, 2009b; Yiu 2007; Li 2006) (see Table overleaf). In the meantime, given the often unsatisfactory outcomes from conventional treatments, acupuncture may be a worthwhile option to consider, probably as part of a combined approach. There is evidence to support its effectiveness for some of the common symptoms – chronic pain, insomnia, depression (refer to the relevant Fact Sheets for details), but for chronic fatigue syndrome as a whole there is a need for more, and higher quality, research.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurotransmitters. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for insomnia (Wu 1999).

Acupuncture may help to relieve symptoms of chronic fatigue syndrome such as musculoskeletal pain, headache, sleep problems, tiredness and depression by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Zhao 2008).
  • stimulating opiodergic neurons to increase the concentrations of beta-endorphin, so relieving pain (Cheng 2009).
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003).
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which can reduce swelling and pain.
  • reducing insomnia through increasing nocturnal endogenous melatonin secretion (Spence 2004).

Insomnia

According to a survey by the Office of National Statistics (ONS 2000), around 29% of adults reported experiencing sleep problems the week before interview. Such problems are more common in women (34%) than men (24%) (ONS 2000).

Insomnia that is not due to an organic cause is defined as a condition of unsatisfactory quantity and/or quality of sleep lasting for a considerable period of time (WHO 2007). It includes difficulty falling asleep, difficulty staying asleep, or early final wakening (WHO 2007; American Psychiatric Association, 2000).

The choice of treatments for insomnia depends on both the duration and nature of presenting symptoms. People should be given advice on appropriate routines to encourage good sleep, such as avoiding stimulants and maintaining regular sleeping hours with a suitable environment for sleep (NICE 2004). Other non-pharmacological interventions, such as cognitive behavioural therapy, are used for the management of persistent insomnia (NICE 2004). Drugs to induce sleep (hypnotics) can provide relief from the symptoms of insomnia, but do not treat any underlying cause. Expert bodies have long advised that use of hypnotics for insomnia should be limited to short courses for acutely distressed patients (Joint Formulary Committee 2009).

Despite this, in England, around 10 million prescriptions for hypnotics are dispensed every year (PCA 2007). Around 80% of all such prescriptions are for people aged 65 years or over (Curren 2003), and many patients remain on the drugs for months or years (Taylor 1998). Such prescribing carries many potential hazards for patients, including risk of dependence, accidents and other adverse effects on health (Joint Formulary Committee 2009).

References

American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision). Washington DC: American Psychiatric Association.

Curran HV et al. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Psychol Med 2003; 33: 1223-37.

Joint Formulary Committee. British National Formulary. Edition 58. London: Royal Pharmaceutical Society of Great Britain and British Medical Association, September 2009.

[online]. Technology appraisal 77. Available: http://www.nice.org.uk/nicemedia/pdf/TA077fullguidance.pdf

Office of National Statistics 2000. Psychiatric Morbidity among Adults living in Private Households. [online] Available: http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf

Prescription cost analysis (PCA). 2007 [online]. Available: http://www.ic.nhs.uk/cmsincludes/_process_document.asp?sPublicationID=1206971516809&sDocID=3884.

Taylor S et al. Extent and appropriateness of benzodiazepine use. Results from an elderly urban community. Br J Psychiatry 1998; 173: 433-8.

What’s wrong with prescribing hypnotics? Drug and Therapeutics Bulletin 2004; 42:89-93.

World Health Organization 2007. International Statistical Classification of Disease 10th revision (ICD-10) [online]. Available: http://apps.who.int/classifications/apps/icd/icd10online/

How acupuncture can help

Reviews are consistent in showing that most trials have found acupuncture (or acupressure or related procedures) to be significantly more effective than hypnotic drugs (usually benzodiazepines), no treatment, or sham acupuncture (Sun 2010, Cao 2009, Yeung 2009, Lee 2008, Cheuk 2007). Meta-analysis supports these conclusions. Nevertheless, reviewers have been cautious in their recommendations because of the poor methodological quality of most trials; rigorous, large scale studies are needed to address this. There are now substantial numbers of more recent (published subsequent to the reviews’ data collection) randomised trials with positive results, though not for every sleep measure used in every trial (Luo 2010, Reza 2010, Yeung 2009, Lee 2009a, Huang 2009, and others). On the evidence that we have, given that acupuncture appears to be at least as effective as existing conventional drugs, without their level of side effects, it could be considered as one of the therapeutic options for insomnia. (See table overleaf for details).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for insomnia and anxiety (Hui 2010).

Research has shown that acupuncture treatment may specifically be of benefit in people with insomnia by:

  • increasing nocturnal endogenous melatonin secretion (Spence et al 2004).
  • stimulating opioid (especially b-endorphin) production and µ-opioid receptor activity (Cheng et al 2009).
  • increasing nitric oxide synthase activity and nitric oxide content, helping to promote normal function of brain tissues, which could help to regulate sleep (Gao et al 2007).
  • increasing cerebral blood flow (Yan 2010)
  • reducing sympathetic nervous system activity, hence increasing relaxation (Lee 2009a)
  • regulating levels of neurotransmitters (or their modulators) such as serotonin, noradrenaline, dopamine, GABA and neuropeptide Y; hence altering the brains’s mood chemistry to help to increase relaxation and reduce tension (Lee 2009b; Samuels 2008; Zhou 2008).

Acupuncture can be safely combined with conventional medical treatments for insomnia, such as benzodiazepines, helping to reduce their side effects and enhance their beneficial effects (Cao et al 2009).

Stress

Up to half a million people in the UK experience work-related stress every year, which often results in illness.(Health and Safety Executive 2011) Other factors that affect stress levels include alcohol, smoking, exams, pregnancy, divorce, moving, death in family, lifestyle, drugs, poor nutrition and unemployment.

The signs of stress can vary from one individual to the next.(NHS Choices 2011) They may manifest physically as an illness, tiredness or lethargy, or as symptoms such as sore, tight muscles, dull skin, lank hair, or erratic sleep patterns. Mental stress can result in depression, mood swings, anger, frustration, confusion, paranoid behaviour, jealousy or withdrawal.

Conventional treatments include medication such as anti-anxiety drugs, cognitive behavioural therapy and relaxation techniques.(NHS Choices 2011)

References

Health and Safety Executive, 2011.Stress-related and psychological illness [online]. Available: http://www.hse.gov.uk/statistics/causdis/stress/scale.htm

NHS Choices, 2011. Stress Management [online]. Available: http://www.nhs.uk/livewell/stressmanagement/Pages/Stressmanagementhome.aspx

How acupuncture can help

Stress is a common complaint cited by acupuncture patients, with a variety of possible associated symptoms. The most prevalent of these is anxiety, for which there is information about acupuncture treatment in the Anxiety Fact Sheet. There are also factsheets on other conditions that are affected by stress, such as back pain, chronic pain, depression, headache, insomnia, irritable bowel syndrome, menopausal symptoms, migraines, premenstrual syndrome and urinary incontinence.

Aside from such associated conditions, there is little clinical research on stress per se. One small randomised controlled trial (RCT) suggested that acupuncture might be successful in treating the symptoms of chronic stress (Huang 2011). Another three RCTs have investigated acupuncture in very specialised situations: a) as an adjunct to anaesthesia, it was found to help keep haemodynamics stable and reduce the stress response during laparoscopic cholecystectomy (Wu 2011); b) it did not reduce salivary cortisol concentrations (and so may not be able to reduce emotional stress) in female dysphonic speakers (Kwong 2010); c) acute acupuncture appeared to control excessive sympathetic excitation during mental stress in patients with advanced heart failure (Middlekauff 2002). A crossover study with healthy individuals subjected to stress testing found acupuncture at a point indicated for stress was more effective than a ‘control’ point (Fassoulaki 2003). Several uncontrolled studies have looked at various aspects of stress and the effects of acupuncture. One found that it might be effective in attenuating psychological distress, as well as increasing cellular immunity (Pavao 2011). In another, acupuncture was associated with less stress around embryo transfer and improved pregnancy rates in women having IVF (Balk 2010). In a small pilot study, the use of one particular acupuncture point led to marked reductions in stress (Chan 2002).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically benefit anxiety disorders and symptoms of anxiety by:

  • Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
  • Improving stress induced memory impairment and an increasing AchE reactivity in the hippocampus (Kim 2011);
  • Reducing serum levels of corticosterone and the number of tyrosine hydroxylase-immunoreactive cells (Park 2010);
  • Regulating levels of neurotransmitters (or their modulators) and hormones such as serotonin, noradrenaline, dopamine, GABA, neuropeptide Y and ACTH; hence altering the brain’s mood chemistry to help to combat negative affective states (Lee 2009; Cheng 2009; Zhou 2008);
  • Stimulating production of endogenous opioids that affect the autonomic nervous system (Arranz 2007). Stress activates the sympathetic nervous system, while acupuncture can activate the opposing parasympathetic nervous system, which initiates the relaxation response;
  • Reversing pathological changes in levels of inflammatory cytokines that are associated with stress reactions (Arranz 2007);
  • Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • Reversing stress-induced changes in behaviour and biochemistry (Kim 2009).

Substance misuse

In the UK, the prevalence of substance misuse is around 9 per 1,000 of the population aged 15-64 years, and around 3 per 1,000 inject drugs, in most cases opioids (NICE 2007). In 2005/6, around 181,000 people were using drug treatment services in England and Wales (Commission for Healthcare Audit and Inspection 2006). Also, research in England in 2005 estimated that 7.1 million people, or 23% of the adult population, could be categorised as hazardous or harmful alcohol users (Drummond 2005). Indeed, in England, 150,000 hospital admissions annually result from acute or chronic alcohol use, and alcohol use is implicated in 33,000 deaths each year (Academy of Medical Sciences 2004).

Dependence on drugs is a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance takes on a much higher priority for a given individual than other behaviours that once had a greater value (WHO 2007). Drugs of abuse include cannabis, opioids (opiates), CNS stimulants (cocaine, crack, amphetamines, ecstasy, crack), CNS depressants (barbiturates, benzodiazepines, alcohol), hallucinogens (LSD, psilocybin), and volatile substances (glues, gases, aerosols) (DTB 1997).

Opioid misuse and dependence are associated with a wide range of problems, such as overdose; infection with HIV, hepatitis B or hepatitis C; thrombosis; anaemia; poor nutrition; dental disease; criminal behaviour; relationship breakdown; lost productivity; unemployment; imprisonment; social exclusion; and prostitution, as well as withdrawal symptoms (Prodigy 2006; Gowing 2006; National Treatment Agency for Substance Misuse 2006). Problems associated with excessive alcohol use include hypertension, accidental injury, hand tremors, duodenal ulcers, gastrointestinal bleeding, cognitive impairments, anxiety and depression (Saunders 1990). The development of alcohol dependence appears to involve changes in brain neurotransmission (Littleton 1994; Tsai 1995).

Treatment programmes to help people with drug and alcohol problems include a range of individualised psychosocial interventions such as counselling, self-help groups, and rehabilitation programmes, in addition to medication.

References

Academy of Medical Sciences. Calling time: the nation’s drinking as a major health issue. London: AMS, 2004.

Commission for Healthcare Audit and Inspection, 2006. Improving services for substance misuse. A joint review [online]. Available: http://www.healthcarecommission.org.uk/_db/_documents/improving_services_for_substance_misuse.pdf

Drummond C et al. Alcohol needs assessment research project. London: Department of Health, 2005.

Gowing L et al. Buprenorphine for the management of opioid withdrawal. The Cochrane Database Systematic Reviewers. 2006, Issue 2. Art. No.: CD002025. DOI:10.1002/14651858.CD002025.pub3

Helping people who misuse drugs. DTB 1997; 35: 18-22.

Littleton J, Little H. Current concepts of ethanol dependence. Addiction 1994; 89: 1397-412.

National Institute for Health and Clinical Excellence, 2007. Technology Appraisal Guidance 114. Methadone and buprenorphine for the management of opioid dependence [online]. Available: http://www.nice.org.uk/guidance/TA114/guidance/pdf/English/download.dspx.

National Treatment Agency for Substance Misuse, 2006. Models of care for treatment of adult drug misusers: update 2006 [online]. Available: www.nta.nhs.uk/publications/mocpubs.htm

Prodigy guidance, 2006. Opioid dependence [online]. Available: www.prodigy.nhs.uk/opioid_dependence/view_whole_guidance

Saunders J, Conigrave K. Early identification of alcohol problems. Can Med Assoc J 1990;143:1060-8.

Tsai G et al. The glutamatergic basis of human alcoholism. Am J Psychiatry 1995; 152: 332-40.

World Health Organization 2007. International Statistical Classification of Disease 10th revision (ICD-10) [online]. Available: http://apps.who.int/classifications/apps/icd/icd10online/

How acupuncture can help

Acupuncture is used extensively, and worldwide, in substance misuse treatment centres. This stems from the development of a simple 5-point auricular acupuncture protocol at New York’s Lincoln Hospital in the 1970’s, originally for drug users but subsequently extended to tobacco, alcohol and other addictive substances and behaviours. The protocol was designed to operate within Western health settings and mutual peer support systems, not as an isolated treatment.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Wu 1999).

Results from randomised controlled trials (Tian 2006; Berman 2001; Hyun 2010; Yeh 2009; Wu 2007) and systematic reviews (Cho 2009; Liu 2009; Gates 2006; White 2006; Jordan 2006; Mills 2005) looking at the effects of acupuncture on withdrawal symptoms and relapse rates related to alcohol, opiate, nicotine and cocaine misuse have been equivocal, mainly because of the poor quality of the research. The acupuncture provided in the trials has sometimes been inadequate, sham controls have often been inappropriate, many studies are too small and high dropout rates are common. Acupuncture has most commonly been evaluated against a sham control, which may in effect be no more than comparing two versions of acupuncture. There appears to be a discrepancy between results in experimental settings and those in normal practice, so context effects may be important (Margolin 2003). Better studies are required, especially those comparing acupuncture to usual care, and as an adjunct to usual care rather than a stand-alone intervention (See Table below).

Acupuncture may help relieve symptoms of drug withdrawal by:

  • normalising the release of dopamine in the mesolimbic system. This reduces the over-stimulating effects of abused drugs and modifies behaviours associated with addiction such as those around desire and reward. Several brain neurotransmitter systems, for example serotonin, opioid and GABA, are implicated in this (Lee 2009a, Yang 2008, Zhao 2006)
  • reducing anxiety (Samuels 2008). Acupuncture can alter the brain’s mood chemistry, reducing serotonin levels (Zhou 2008) and increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009b; Cheng 2009);
  • modulating postsynaptic neuronal activity in the nucleus accumbens and the striatum to reduce nicotine addiction (Chae 2004) and increasing corticotrophin-releasing factor to attenuate anxiety-like behaviour following nicotine withdrawal (Chae 2008);

Vertigo

People with vertigo have the illusion that the environment is moving about them, or that they are moving with respect to the environment.(DTB 2009) The condition usually originates in the peripheral nervous system, for example, due to a disorder of the inner ear such as Ménière’s disease, benign paroxysmal positional vertigo (BPPV), or labyrinthitis and vestibular neuritis. It can also be due to pathology in the CNS (central vertigo), such as haemorrhages, ischaemia, or CNS tumours, infection or trauma. Neck pathology can also cause vertigo.

Ménière’s disease is a chronic progressive disease that damages the balance and hearing parts of the inner ear, leading to vertigo, tinnitus, sensorineural hearing loss, nausea and vomiting. (Friberg 1984) In Europe, the incidence of Ménière’s disease is about 50–200/100 000 a year. (Cawthorne 1954; Stahle 1978) It is most common between 40–60 years of age, although younger people may be affected. (Moffat 1997; Watanabe 1995) The aetiology and treatment of the disease is not fully understood. Conventional medical treatments include drugs, diet and surgery. The vertigo associated with BPPV has a spinning component, is of short duration and can only be induced by a change in position. The condition can result in nausea and visual disturbances. Around 17–42% of people with vertigo are eventually diagnosed with BPPV. (Bhattacharyya 2008) It is thought to be caused by canalithiasis (tiny fragments of debris in the inner ear labyrinth). Treatment usually comprises certain movements to reposition the canalith, known as the Epley manoeuvre. Drugs may be used in severe acute cases, but are not usually indicated, and surgery is used as a last resort. Labyrinthitis and vestibular neuritis are most commonly caused by a viral infection of the inner ear. Both conditions typically cause vertigo, often with nausea and vomiting. In most people, the symptoms gradually ease and disappear within a few weeks. Medication (e.g. prochlorperazine) may be given to help relieve symptoms.

References

Bhattacharyya N et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008; 139 (Suppl 4): s47–s81.

Cawthorne T, Hewlett AB. Ménière’s disease. Proc Royal Soc Med 1954; 47: 663–70.

Friberg U et al. The natural course of Ménière’s disease. Acta Otolaryngol Suppl 1984; 406: 72–7.

Macleod D, McAuley D. Vertigo: clinical assessment and diagnosis. Brit J Hosp Med 2008; 69: 330-4.

Management of benign paroxysmal positional vertigo. DTB 2009 ;47: 62-6.

Moffat DA, Ballagh RH. Ménière’s disease. In: Kerr AG, Booth JB, eds. Scott-Brown’s otolaryngology. 6th ed. Oxford: Butterworth-Heinemann, 1997.

Sajjadi, H, Paparella MM. Ménière’s disease. Lancet 2008: 372: 406-14.

Stahle J et al. Incidence of Ménière’s disease. Arch Otolaryngol 1978; 104: 99–102.

Watanabe Y et al. Epidemiological and clinical characteristics of Ménière’s disease in Japan. Acta Otolaryngol Suppl. 1995; 519: 206–10.

How acupuncture can help

A systematic review of research on all types of acupuncture for Ménière’s syndrome has suggested a beneficial effect from acupuncture, both for patients in the acute phase of the disease and for those who have had the syndrome for a number of years (Long 2011). Randomised controlled trials have been almost entirely Chinese and most have compared different types of acupuncture (or acupuncture and related procedures), rather than acupuncture vs. non-acupuncture/other therapies. Many have focused specifically on cervical vertigo, involving insufficient blood supply through the vertebral arteries (which supply the brainstem and cerebellum). Recent examples found that: combined therapy of electroacupuncture and acupoint injection was more effective than routine acupuncture or electroacupunture alone for cervical vertigo (Li 2011); acupoint massage was superior to manipulation (Kang 2008); acupuncture was better than moxibustion for relieving or eliminating symptoms of vertigo, with no adverse effects (Zhang 2008); and that ginger moxibustion was superior to acupuncture treatment (Xiaoxiang 2006). A controlled nonrandomised study found both penetrating needling on head points and traditional acupuncture could effectively relieve cervical vertigo, reduce the attack frequency and improve accompanying symptoms (Qi 2011).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010).

Acupuncture may help to relieve vertigo by:

  • activating the left superior frontal gyrus, anterior cingulate gyrus, and dorsomedial nucleus of the thalamus, and stimulating the release of acupuncture-specific neural substrates in the cerebellum (Yoo 2044);
  • increasing blood flow velocity in the vertebral-basilar artery, thus improving cervical vertigo (Li 2011; Qi 2011; Kang 2008)
  • increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states;
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987; Zhao 2008; Cheng 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling

Hypertension

Hypertension is a major risk factor for stroke (both ischaemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, peripheral vascular disease, cognitive decline and premature death worldwide.(Kearney 2005) If the condition is untreated, there is a progressive rise in blood pressure, which often results in a treatment resistant state due to vascular and renal damage (itself caused by the untreated hypertension).(NICE 2011)

At least 25% of the adult population in the UK have hypertension (i.e. a blood pressure of 140/90mmHg or more), and over half of those over the age of 60 years are affected.(NICE 2011) The prevalence is strongly influenced by age and lifestyle factors. Raised systolic pressure is the more dominant feature of hypertension in older patients, while raised diastolic pressure is more common in younger patients (i.e. those under 50 years of age).(NICE 2011) Because routine periodic screening for high blood pressure is commonplace in the UK, the diagnosis, treatment and follow-up of patients with hypertension is one of the most common interventions in primary care; it actually accounts for around 12% of consultations in general practice.(NICE 2011)

Lifestyle interventions to lower blood pressure include reducing salt, caffeine and alcohol intake, taking regular exercise, stopping smoking and relaxation therapies (e.g. meditation, yoga). Approximately £1 billion was spent on drugs for hypertensions in the UK in 2006.(NICE 2011) Drugs used to treat hypertension include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium-channel blockers, diuretics and beta-blockers.

References

Kearney PM et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217–23.

National Clinical Guideline Centre. Hypertension. The clinical management of primary hypertensions in adults. Clinical Guideline 12. August 2011. Available: http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a severe, long lasting psychological reaction to a distressing event, which can cause significant impairment (Reed 2012). It can develop after a major traumatic event (such as a serious accident, a violent personal assault or military combat), and can affect people of all ages.

The general signs of stress can vary from one individual to the next (NHS Choices 2011). They may manifest physically as an illness, tiredness or lethargy, or as symptoms such as sore, tight muscles, dull skin, lank hair, or erratic sleep patterns. Mental stress can result in depression, mood swings, anger, frustration, confusion, paranoid behaviour, jealousy or withdrawal. Specific signs of PTSD include vivid memories of the traumatic event, such as flashbacks when awake or nightmares when asleep; hyperarousal, when the person is hypervigilant for threats and may have insomnia, irritability and difficulty concentrating; and an inability to experience feelings or amnesia about parts of the event (Reed 2012; NICE CKS).

Symptoms usually start in the first month after the traumatic event. In about 15% of people, symptoms can be delayed by months or years, but they usually appear within 6 months (Reed 2012; NICE CKS). In around 65% of adults, symptoms resolve naturally, although this may take several months. In the rest, symptoms are longer lasting and can be severe.

Conventional treatments for PTSD include medication such as anti-anxiety drugs, cognitive behavioural therapy and relaxation techniques (NHS Choices 2011).

References

NHS Choices. Post-traumatic stress disorder [online].Available: http://www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Introduction.aspx

NICE Clinical Knowledge Summaries. Post-traumatic stress disorder [online]. Available: http://cks.nice.org.uk/post-traumatic-stress-disorder

Reed RV et al. Post traumatic stress disorder. BMJ 2012; 344 e3790

How acupuncture can help

This factsheet looks at the evidence for acupuncture in the treatment of PTSD. There are related factsheets on anxiety, stress and depression.

There are preliminary positive findings for acupuncture in the treatment of chronic anxiety associated with PTSD. A systematic review of acupuncture for PTSD found that the evidence of effectiveness is encouraging (Kim 2013): all four reviewed randomised controlled trials (RCTs) indicated that acupuncture was equal to or better than orthodox treatments, or that it added extra effect to them when used in combination. Three of the four are Chinese studies that used earthquake survivors and one similar RCT (Wang 2012) was too recent to be included in the review. It found that both electroacupuncture and paroxetine resulted in significantly improved scores for PTSD, but that the improvement was greater with electroacupuncture. There is also some evidence that the acupuncture effects may continue for at least a few months after the treatment course is finished (Hollifield 2007).

A review that looked at the effects of combining brief psychological exposure with the manual stimulation of acupuncture points in the treatment of PTSD and other emotional conditions found evidence suggesting that tapping on selected points during imaginal exposure quickly and permanently reduces maladaptive fear responses to traumatic memories and related cues (Feinstein 2010).

Kim’s review (Kim 2013) also included two uncontrolled trials (they too had positive outcomes). A more recent uncontrolled pilot study found that acupuncture appeared to be a therapeutic option in the treatment of sleep disturbance and other psycho-vegetative symptoms in traumatised soldiers (Eisenlohr 2012).

Although more high quality trials are needed to substantiate these results, the overall evidence does lie promisingly in a positive direction, and, given the very low level of side effects and lack of demonstrably superior outcomes from other interventions, acupuncture could be considered as one possible therapeutic option alongside the existing repertoire. (See table overleaf)

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically benefit anxiety disorders and symptoms of anxiety and stress by:

Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010);
Regulating levels of neurotransmitters (or their modulators) and hormones such as serotonin, noradrenaline, dopamine, GABA, neuropeptide Y and ACTH; hence altering the brain’s mood chemistry to help to combat negative affective states (Lee 2009; Zhou 2008);
Stimulating production of endogenous opioids that affect the autonomic nervous system (Arranz 2007). Stress activates the sympathetic nervous system, while acupuncture can activate the opposing parasympathetic nervous system, which initiates the relaxation response;
Reversing pathological changes in levels of inflammatory cytokines that are associated with stress reactions (Arranz 2007);

Dementia

Dementia

An estimated 637,000 people in the UK have dementia syndrome and the annual cost of their care is £17 billion(Alzheimer’s Society 2007). Alzheimer’s disease is the commonest type of dementia (affecting around 60% of those with dementia), followed by vascular dementia (20–25%) and dementia with Lewy bodies (10–15%)(Overshott 2005; DTB 2003).

About 80% of people with dementia will have behavioural changes or psychological symptoms at some time (Overshott 2005), which can reduce quality of life for both patients and carers, and often result in transfer to residential care and higher costs(Finkel 2000; O’Donnell 1992; Lawlor 2002; Donaldson 1997). The symptoms can include anxiety, depressed mood, psychotic symptoms, and behavioural symptoms such as aggression, agitation, wandering, sexual disinhibition, and screaming and swearing(Finkel 1997). Psychotic symptoms such as delusions and hallucinations occur in 30–50% of all patients with dementia(Jeste 2000), and in about 80% of patients with dementia with Lewy bodies(McKeith 2006).

 

There are 2 main types of medication used to treat Alzheimer’s disease – cholinesterase inhibitors and NMDA receptor antagonists. Cholinesterase inhibitors include donepezil hydrochloride (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). The NMDA receptor antagonist is memantine (Ebixa). Drugs may also be used to treat symptoms of dementia, for example, antipsychotic drugs, antidepressants, anti-anxiety drugs and hypnotics(Burns 2009). However, the generally recommended practice for such symptoms of dementia is to try non-drug methods first (e.g. behavioural and psychological interventions, occupational activities, environmental approaches), unless the patient is severely distressed or there is an immediate risk of harm to themselves or others(DTB 2003; NICE 2006). NICE guidelines recommend that people with dementia with mild-to-moderate non-cognitive symptoms should not be prescribed antipsychotic drugs, and that those with severe non-cognitive symptoms (i.e. psychosis and/or agitated behaviour causing significant distress) should only be offered treatment with an antipsychotic drug if specific conditions have been met(NICE 2006).

 

References

 

Alzheimer’s Society 2007. Dementia UK: the full report. London: AS. Available: http://alzheimers.org.uk/site/scripts/download_info.php?fileID=2

 

Burns A. Dementia. BMJ 2009; 338: b75.

 

Donaldson C et al. The impact of the symptoms of dementia on caregivers. Br J Psychiatry 1997; 170: 62–8.

 

Drugs for disruptive features in dementia. DTB 2003; 41: 1–4.

 

Finkel S. Introduction to behavioural and psychological symptoms of dementia (BPSD). Int J Geriatr Psychiatry 2000; 15: S2–4.

 

Finkel S et al. Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment. Int J Geriatr Psychiatry 1997; 12: 1060–1.

 

Jeste DV, Finkel SI. Psychosis of Alzheimer’s disease and related dementias: diagnostic criteria for a distinct syndrome. Am J Geriatr Psychiatry 2000; 8: 29–34.

 

Lawlor B. Managing behavioural and psychological symptoms in dementia. Br J Psychiatry 2002; 181: 463–5.

 

McKeith I. Dementia with Lewy bodies. In: Agronin ME, Maletta GJ (Eds). Principles and Practice of Geriatric Psychiatry. Philadelphia: Lippincott Williams and Wilkins, 2006.

 

NICE 2006. Dementia: supporting people with dementia and their carers in health and social care. NICE clinical guideline 42 [online]. Available: http://www.nice.org.uk/guidance/CG42

 

O’Donnell BF et al. Incontinence and troublesome behaviours predict institutionalisation in dementia. J Geriatr Psychiatry Neurol 1992; 5: 45–52.

 

Overshott R, Burns A. Treatment of dementia. J Neurol Neurosurg Psych 2005; 76 (suppl V): v53–9.

 

How acupuncture can help

 

This factsheet focuses on the evidence for acupuncture in dementia. One systematic review found that the evidence available for acupuncture does not demonstrate effectiveness in Alzheimer’s disease (Lee 2009),although only three randomised controlled trials (RCTs) were located for this. By contrast, a review for dementia in general found 22 RCTs, which demonstrated a significant positive advantage for acupuncture over control groups (Gu 2008). Since most of the trials were for vascular dementia, it’s notable that a Cochrane review one year earlier had found no suitable RCTs at all for this condition (Peng 2007)

 

There have been several randomised controlled trials published since these systematic reviews, all with promising results. All are for vascular dementia (not Alzheimers) and all are from China. All of them compared acupuncture to medication; two also used a combined acupuncture plus medication group. In five trials, acupuncture was significantly better than medication (Zhang 2011, Chen 2011, Wang 2010, Zhang 2008, Liu 2008b) and in three it was similar in effect (Zhao 2009, Chen 2009, Liu 2008a). Various different acupuncture treatment modalities were used: manual needling (Zhang 2011, Liu 2008a), electroacupuncture (Zhao 2009, Zhang 2008, Liu 2008b), moxibustion (Chen 2011, Wang 2010) and ear taping/pressing (Chen 2009). Most studies used recognised outcomes measures relevant to dementia and some also investigated possible biochemical mechanisms (see below).

 

Despite this, there is certainly a need for larger, better quality trials, preferably from a wider range of countries.

 

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically help in dementia by:

  • regulating neuropeptide substances (somatostatin and arginine vasopressin) relevant to learning and memory (Chen 2011; Wang 2010);
  • reducing the levels of 8-OHdG (Shi 2012) and decreasing lipid peroxidation in the brain (Zhu 2010; Yang 2007), suggesting that acupuncture helps to prevent oxidative damage;
  • activating certain cognitive-related regions in the brain(Wang 2012);
  • decreasing the overproduction of nitric oxide and strengthening the ability to eliminate free radicals (He 2012);
  • decreasing cholinergic neuron damage and reducing the abnormal activation and hyperplasia of astrocytes (Miao 2009);
  • decreasing the number of activated glial cells so as to protect the neurons (Zhu 2009);
  • lowering acetylcholinesterase activity (Yang 2007);
  • suppressing vascular dementia-induced increase of interleukin-1beta and tumor necrosis factor-alpha levels in the hippocampus (Li 2007);
  • improving glucose metabolism in the bilateral frontal lobes, bilateral thalamus, temporal lobe and lentiform nucleus (Chen 2006);
  • acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010).

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