Traditional Chinese medicine (TCM) developed under Daoist and later Confucian influences (1). According to Chinese medicine, body and mind are inseparable; nondualistic aspects that have a bidirectional and equal functional relationship; together they form patterns where somatic-physiologic events and mental-emotional experiences coexist and influence each other. All aspects of life unfold within a universal stratum known as qi (pronounced “chee”), an interconnected matrix, rather than a fixed, able entity (2) where the capacity of life to maintain and transform itself, manifests in the myriad phenomena (3). Functional interconnections among the individual elements of a pathologic process are more important than any individual element (4). In medicine, there are several forms of qi, believed to be partly inherited from the parents, partly obtained from food, and maintained at different levels during life. For example, wei qi is the defensive energy that protects us against external pathologic factors, environmental influences that play a part in disease (wind cold, dampness); and rong or ying qi is the nourishing energy obtained from food (3,5).

The dynamic equilibrium of qi is maintained by the interaction of two complementary active principles, yin and yang (6), which represent the natural process of continuous change (3). Yin and yang are rooted in each other; they are complementary and depend on each other. Health—both physical and mental—is defined as the balance between yin and yang (6) and in medicine yin and yang are used to describe life processes and classify pathologic disturbances (Table 15.1). Clinically, the body is described in yin and yang terms, where yin corresponds to the interior, the front and the lower half of the body, and yang corresponds to the exterior, the back and the upper half of the body (7). Yin and yang are relative; for example, the head is considered yang relative to the arm, but the arm is considered yang relative to the foot.

The balance between yin and yang depends on the capacity of an organism to adapt to change and to maintain equilibrium (6). Sickness is the result of vacuity (deficiency, hypofunction of any physiologic process, and decreased resistance to stress or infection) or the result of repletion (excess, hyperfunction or obstruction of qi of any physiologic process, and increased reactivity to stress or infection). Both vacuity and repletion represent disharmonies between yin and yang (6). For example, a patient who is chronically fatigued may be said to have an “insufficiency of qi” in a particular organ, and this organ’s corresponding meridian would therefore be targeted for acupuncture treatment with the goal of “supplementing,” or strengthening of the qi. Other conditions, such as inflammatory processes, are described as excess conditions, and are treated with acupuncture techniques aimed at “draining,” the repletion by releasing, for example, accumulated qi (3,8).

The homeostasis of the organism, the balance of yin and yang, is sustained by the circulation of qi along channels, i.e., qi pathways that form a network connecting the surface of the
body with the internal organs and serving as a two-way communication system (9). Twelve regular channels correspond to 12 different organs and work in pairs, with one yin and one yang function interconnected (3,6,7) (Table 15.2). The organs in Chinese medicine are defined as functional networks and often do not directly correspond to the specific somatic structures or physiologic actions defined by biomedicine. For example, in TCM, the heart houses the “spirit,” the seat of consciousness and mental function, and the spleen regulates reflection and thought. A “deficiency of the kidney” in TCM may not necessarily refer to kidney disease or insufficiency per se, but rather to a metabolic dysfunction in an area controlled by the kidney, for example, reproduction. TCM also defines certain unorthodox organs such as the triple heater (or triple burner), which comprises the functions of organs in the thorax, abdomen, and pelvis; and the protector of the heart (or master of the heart), which corresponds to the pericardium, the membrane that envelops the heart. These “organs” have their own unique functions as well; for example, the triple heater is thought to regulate body fluids, and the pericardium protects the heart from adverse influences.

Other important channels do not correspond to organs per se; for example, the governor vessel, which regulates the overall yang of the organism and the conception vessel, which subsumes the overall yin functions run along the vertical midline of the body (governor vessel along the back and conception vessel along the front) and unlike the other organ channels, do not run bilaterally.

Acupuncture points, which are found usually in depressions or crevices between bones and sinews, have defined therapeutic actions and represent different qualities of qi (3); they carry out different functions within their corresponding organ’s domain, and may work
independently or in combination with points on the same or other channels, to produce a desired clinical effect. Approximately 365 acupuncture channel points have been defined in the Classical literature; many other nonchannel and miscellaneous points are also used in treatment.

Acupuncturists diagnose and treat illness using a variety of techniques. The information sought is sensory and qualitative (2), rather than quantitative. To begin with, a very thorough diagnostic interview is performed. The clinician will ask about presenting symptoms and past medical history, much like a regular physician, but may also inquire about personality traits, taste, and color preferences, in order to weave symptoms and signs into a pattern, a description of the patient’s imbalance. Palpation of specific points on the body may identify tenderness and suggest illness in a particular organ domain. Inspection of the tongue and palpation of the wrist pulses are two very important and complex assessing skills used by the acupuncturist to identify the nature of the presenting condition and to determine adequate treatment for each patient (10); they may even be used as the sole diagnostic tools in cases where the clinician and the patient do not speak the same language. TCM defines 12 different pulses, each corresponding to a different organ. There are more than two-dozen ways in which to describe the quality of a pulse (e.g., wiry, bounding, viscous, floating, etc.), and these qualities may suggest the nature of the underlying problem (11). The tongue surface map corresponds to the different organs, laid out in more or less anatomic orientation, with the heart at the tip of the tongue, and the reproductive organs near the base. Variations in the color, coating, and general quality of the tongue may indicate particular disease states (10).

Based on the information gathered, the clinician will diagnose an imbalance of a particular organ system or of various systems, and develop a treatment approach addressing the entire clinical picture. Usually, the patient will have needles placed in different areas of the body corresponding to the channels addressed, which may include the extremities, the trunk, and pelvis, as well as the head. Needle insertion may be associated with various sensations such as tingling, distension, or aching but it is seldom bothersome, especially once the patient is accustomed to the procedure. The main function of the needles is to access the qi at the specific points, activate it in cases of deficiency, and disperse it in cases of excess as a way of restoring
balance. This is accomplished by specific manipulation of the needle, usually a clockwise or counterclockwise rotation performed at different times throughout the treatment, which depending on the style of treatment, typically lasts 20 to 45 minutes (8).

Acupuncturists frequently use electric stimulation at different points, as a means of activating qi more continuously and/or more strongly during treatment. Heating the points directly or acupuncture needle with moxa (mugwort) or a heat lamp can also be done to achieve stronger supplementation of qi and to warm the body (2,8). Many acupuncturists are also trained in Chinese herbal medicine, and may combine herbs with acupuncture treatment, in order that the two may complement each other’s effect. With repeated sessions over time, the treatment program is expected to result in a clinical effect, correcting the imbalance, and restoring normal function in the specific organ system(s) in question.

Acupuncture treatments are typically administered 2 to 3 times per week at first, and if effective, they are later decreased to monthly or even less frequently, as a maintenance treatment. Because TCM considers many illnesses the results of lifestyle and external stressors (e.g., poor dietary practices, frequent air travel, or long work days coupled with insufficient sleep), many individuals will be advised to obtain regular treatment at prescribed intervals in order to maintain the original benefit, especially in cases where lifestyle changes are not feasible (or desired). In this sense, acupuncture treatment may be viewed as analogous to car maintenance; to continue to function well over time, a car must be tuned up periodically and have minor problems corrected before they become too severe. In today’s managed care environment, appointments multiple times a week are not always possible, and many patients will settle for weekly treatments, which may take longer to exert their full effect.

While acupuncture does not purport to cure the incurable (e.g., cancer and other terminal illnesses) and should never be viewed as a miracle cure, it may be used to ameliorate the pain and discomfort associated with many severe illnesses and to improve function. It may slowly reverse or attenuate the course of chronic illnesses over a longer period of time, hence providing improved quality of life for sufferers of chronic pain syndromes, chronic fatigue, and so on.

Acupuncture has been a staple of Asian medicine for millennia, and its popularity has been growing in the Western world since the early 1970s (12). When discussing acupuncture we must understand that it is a very diverse discipline. There are different schools and styles of acupuncture throughout the world, such as the Chinese, Japanese, Korean, and French schools, and these schools espouse different approaches to diagnosis and treatment. Some may focus on using specific points for specific organ system problems. Others may use combinations of points for specific syndromes defined in terms of the particular branch of medicine; for example, a diagnosis of “spleen and kidney deficiency” might refer to mental fatigue (spleen regulates the thinking process) coupled with general loss of energy (kidney regulates vital energy or qi). (It may interest our readers to know that this condition has also been termed “academician syndrome!”) The French school has developed a system where meridians are linked to form “energetic circuits” that require specific combinations of needles to activate them (7). There are also schools based on microsystems, such as auricular acupuncture, a discipline unto itself that is often used in conjunction with or as an alternative to body acupuncture. Scalp acupuncture and hand acupuncture are other approaches, the former using points exclusively on the head, and the latter using points on the hands that correspond to different organ systems and parts of the body.

While these different styles of acupuncture have many features in common, and practitioners frequently combine techniques from various disciplines, it can be difficult to reconcile them all. Many controversies have arisen as a result of the differences and apparent contradictions between the various schools, and even between practitioners in the same school. For example, the insertion of the needle often causes a dull ache, referred to as de qi (“arrival of qi”) (8). Many schools and practitioners emphasize that acupuncture cannot be effective without the occurrence of de qi, and encourage practitioners to strive to obtain it every time. Others downplay the importance of de qi, and do not worry about obtaining it during treatment sessions. As another example, the auricular acupuncture point map is organized partly in the form of a “homunculus” on the surface of the outer ear, corresponding to the different anatomic regions of the body, much like the homunculus corresponding to the sensory organization of the cerebral cortex. According to the French system developed by PFM Nogier and R Nogier (13), the homunculus faces down, its head positioned in the lower portion of the ear, and its feet in the upper portion. This system, however, is not in complete agreement with others; in Chinese auriculoacupuncture, for instance, the position of certain organs such as the heart may differ from their position described in the Nogier system (14).

As a human skill based on observation, acupuncture has developed to reflect the talents, needs, and expectations, as well as the cultural influences of the different societies where it has prospered (2). Can these seemingly irreconcilable paradigms all be right? The different acupuncture styles have had long and fruitful lives, which suggests that they must all have something beneficial to offer. Like most of the treatments reviewed in this book, acupuncture suffers from a paucity of good quality research data. Much of the published research comes from China, and many of these studies have not been translated into English, thus limiting the opportunity for Western clinicians to assess this work and make educated decisions as to whether or not to recommend acupuncture to their patients. Fortunately, there has been a recent emergence of well-designed clinical studies in the United States and elsewhere that are seeking to understand acupuncture both from a mechanistic standpoint as well as from an efficacy standpoint.

Psychiatry is a particular realm in which acupuncture has been severely understudied, and probably underapplied throughout the centuries. The ancient TCM and acupuncture texts make relatively little mention of applications for mental illness. There are several possible explanations for this. TCM and Eastern medicine in general have regarded mental illness very differently from today’s diagnostic frameworks provided by the DSM-IV and the like. TCM tends to view the human being as a whole entity, and avoids the mind-body dichotomies that are more commonly used in Western medicine. Consequently, it can be argued that any healing approach with acupuncture, regardless of its target symptoms or organs, should have a positive effect on the mind’s well-being. On the other hand, the historic stigmatization of the mentally ill may have led the ancient acupuncturists to avoid the subject altogether, perhaps due to a lack of people willing to come forth and ask for help with their illness. Families may have chosen to keep their mentally ill relatives in the home and away from society at large, for fear of the shame that they could bring upon the family. Indeed, the ancient texts tended to use nonspecific and often pejorative terms such as “madness,” hysteria,” and “epilepsy” (15) when referring to conditions that, upon closer scrutiny, probably corresponded to major depression, generalized anxiety, and so forth. Finally, it is possible that the ancient healers did, in fact, test some of their acupuncture strategies on mentally ill people, only to find that they were of limited effectiveness, and consequently tended to ignore the subject when documenting their ideas for posterity. These are the yet unanswered questions that today’s research seeks to address when characterizing acupuncture and its potential role in the psychiatrist’s armamentarium.

The exact mechanism by which acupuncture works is not well understood. Acupuncture stimulation, either alone, with electricity, or with heat, may function by mediating signals that regulate information exchange across a functional network of interconnected channels, its goal being to restore balance in the living system. Acupuncture points may be said to represent a network of physiologic “hubs” beneath the skin that are rich in nerve, capillary, and lymphatic tissue (16). A number of physiologic investigations suggest functional as well as anatomic uniqueness to the acupuncture points. For example, the surface of the skin directly above acupuncture points conducts electricity more readily than other sections of the skin (16). Also, while the different acupuncture schools may disagree over specific use of individual points and combinations of points, most use the standard set of 365 points. This suggests that the discovery of these points was not arbitrary, but the result of years of an empirical trial-and-error process that produced converging lines of evidence for the known body acupuncture points. It is beyond the scope of this chapter to review how acupuncture might work in its myriad applications; we will instead focus on specific mechanisms that have been proposed that may be particularly relevant to depression and other psychiatric disorders.

It is generally thought that depression is related, at least in part, to imbalances in the neurotransmitter system, manifesting as deficiencies of serotonin, norepinephrine, and dopamine. Antidepressants function in part by changing the equilibrium of these neurotransmitters in the synapse; the increased availability of neurotransmitters, and the resulting interactions with postsynaptic receptors eventually lead to intracellular changes that, over time, may produce the desired alleviation of depression (17). Interactions between acupuncture and the neurotransmitter system have been demonstrated, and may contribute to acupuncture’s clinical effect in mood disorders. For example, electroacupuncture mediates the release of norepinephrine in rats and increases the level of norepinephrine in the caudate nucleus and the hypothalamus (18). Also, levels of monoamine neurotransmitters and their primary metabolites have been found to change in the rat brain after electroacupuncture treatment (19).

Another proposed mechanism of depression involves the endogenous opioid peptides, which are thought to inhibit the hypothalamic-pituitary-adrenal (HPA) axis by influencing the release of hypothalamic corticotropin-releasing factors. This modulation of the HPA axis activity, known to be elevated in depression and related to reduced opioid activity, may account for some of the mechanism of acupuncture, particularly in depression (20). For instance, several studies have shown increased levels of endorphins in the blood and cerebrospinal fluid both during and following acupuncture treatment (21). More recently, increases in plasma and brain tissue levels of neurotransmitters such as endomorphin-1, beta-endorphin, encephalin, and serotonin have been documented following acupuncture (22).

The above evidence suggests that acupuncture may work by increasing serotonergic and/or noradrenergic activity in the synapse, resulting in mechanisms of action analogous to those of the selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). On the other hand, acupuncture’s impact on endogenous endorphins could dampen the activity of the HPA axis and decrease cortisol production. Similar interactions have been proposed for St. John’s wort, as well as for the omega-3 fatty acids, both of which have increasing evidence of antidepressant efficacy (see Chapters 3 and 4).

These proposed mechanisms for acupuncture are highly speculative, and do not begin to explain all the possible effects of acupuncture in general, nor might they account for effects from different styles of acupuncture. For example, auricular acupuncture can supposedly treat the whole organism without a need for body acupuncture, thanks to points in the ear that correspond to specific physiologic functions as well as to an anatomic configuration.
Likewise, hand and scalp acupuncture have their own sets of points and underlying theories that may or may not be congruent with some of the other ones proposed here. These other styles of acupuncture, which are much less understood than body acupuncture, may have other underlying mechanisms of action. More research needs to be carried out in order to understand the underlying mechanisms of acupuncture.

There have been relatively few published studies on the effectiveness of acupuncture treatment for psychiatric disorders, with depression and substance abuse as the best represented disorders. As mentioned earlier, many studies have been published in Chinese language journals, but have not been translated into English. The following sections summarize the findings of studies published in English language journals.

There is limited empirical research evaluating the efficacy and safety of acupuncture for depression. Three recent systematic reviews (23, 24, 25) indicate that there is insufficient evidence to determine acupuncture’s efficacy in the treatment of depression, and emphasize the need for further studies. Several other minor studies of acupuncture as a treatment for depression or depression-like syndromes have been published in China (26, 27, 28) and in eastern Europe, including the former Soviet Union (29, 30, 31, 32). These studies, summarized in a book by Schnyer et al. (33), are difficult to fully evaluate both because the diagnostic criteria used differ from those of the DSM-IV and because most of these studies have not been translated into English, except for the abstracts.