Preliminary findings on choline for bipolar disorder

Choline for bipolar disorder

This post is the 4th in a series on bipolar disorder. Previous posts briefly reviewed conventional pharmacologic treatments, uses of select amino acids and omega-3 fatty acids and a proprietary nutrient formula. This post reviews research findings of studies on the B vitamine choline in the treatment of bipolar disorder. 

Findings on choline and phosphatidylcholine in bipolar disorder 

Choline is a naturally occurring B vitamin necessary for the biosynthesis of the neurotransmitter acetylcholine (Ach). It has been postulated that abnormal low brain levels of acetylcholine cause some cases of mania. Findings of a small placebo-controlled trial suggest that phosphatidylcholine (15 g to 30 g/day) may reduce the severity of mania and depressed mood in bipolar patients. Case reports and case series suggest that choline reduces the severity of mania. 

In a small case study of treatment-refractory, rapid-cycling bipolar patients who were taking lithium, four out of six patients responded to the addition of 2000–7200 mg/day of free choline. It should be noted that two non-responders were also taking high doses of thyroid medication at the same time. Clinical improvement correlated with higher levels of choline in a part of the brain called the basal ganglia as measured using magnetic resonance imaging (MRI). The effect of choline on depressive symptoms in these patients was inconsistent. 

Case reports, open trials and one small double-blind study suggest that supplementation with phosphatidylcholine 15 g to 30 g/day reduces the severity of both mania and depressed mood in bipolar patients, and that symptoms recur when phosphatidylcholine is discontinued.

Choline and phosphatidylcholine are safe and generally well tolerated when taken at doses used to treat bipolar disorder.

Because of the limited number of studies and small study size, findings on choline and phosphatidylcholine in the treatment of bipolar disorder should be regarded as preliminary. 

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution” by Dr. Lake 

Select amino acids and Omega3s are beneficial and safe treatments of bipolar disorder

Integrative Management of Bipolar Disorder: Amino Acids and Omega-3s

This is the second post in a series on integrative management of bipolar disorder. Previous post reviewed conventional psychiatric management of bipolar disorder. The focus of this post is on amino acids and omega-3 essential fatty acids. Future posts will provide concise reviews of evidence for a range of non-pharmacologic treatments of this disorder. 

Amino acids have beneficial effects on depressed mood, anxiety and insomnia in bipolar patients.

Taking the amino acid L-tryptophan 2–3 gm/day or 5-hydroxytryptophan (5-HTP) 25 to 100 mg up to three times a day may have beneficial effects on anxiety associated with mania. L-tryptophan 2 gm can be safely added to mood stabilizers such as lithium and valproic acid at bedtime improving sleep quality in agitated manic patients. Doses of L-tryptophan as high as 15 gm may be required when insomnia is severe (although individuals who take doses this high should be closely monitored by a psychiatrist, and this dosage may be restricted in some countries). Research findings suggest that when added to sedating antidepressants (such as trazodone) taken at bedtime L-tryptophan 2 gm may accelerate antidepressant response and improve sleep quality. Serious adverse effects have not been reported using this protocol. The amino acid L-theanine, a natural constituent of green tea, reduces anxiety by increasing alpha activity and increasing synthesis of the inhibitory neurotransmitter GABA. Noticeable anxiety reduction is generally achieved within 30 to 40 minutes and effective doses range between 200 mg and 800 mg/day. There are no contraindications to taking L-theanine in combination with mood stabilizers. 

Omega-3 fatty acids are beneficial in the depressive phase but do not lessen symptoms of mania.

Countries where there is high fish consumption have relatively lower prevalence rates of bipolar disorder. In a systematic review of controlled trials on omega-3 fatty acids in bipolar disorder only one study was identified in which omega-3s were used adjunctively with a mood stabilizer. The combined treatment protocol resulted in a differential beneficial effect on depressive but not manic symptoms. The reviewers cautioned that any conclusions about the efficacy of omega-3 fatty acids in bipolar disorder must await larger controlled studies of improved methodological quality. Large doses of omega-3 fatty acids may be more effective in the depressive phase of the illness.

Some studies suggest that the omega-3 essential fatty acid ecosapentanoic acid (EPA) at doses between 1 and 4 gm/day may have enhance the effectiveness of atypical antipsychotics used to treat acute mania, however, one placebo-controlled trial failed to confirm an adjuvant effect. The appropriate management of a severely depressed bipolar patient might include a mood stabilizer, an antidepressant and omega-3 fatty acids. 

There are few safety issues.

Rare cases of increased bleeding times, but not increased risk of bleeding, have been reported in patients taking aspirin or anti-coagulants together with omega-3s.

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake MD.

Meditation and Mind-body practices for Treating ADHD

Non-pharmacologic treatments of ADHD

This is the 10th post in a series on complementary and alternative therapies for ADHD. This post comments on research highlights from studies on meditation and mind-body practices as treatments of ADHD. Previous posts briefly reviewed the evidence for a variety of non-pharmacologic treatments including herbals, EEG biofeedback, omega-3 fatty acids, dietary modification, acupuncture and others.

Study design problems and small study sizes make most findings inconclusive

In a systematic review of studies on meditation and mind-body practices (eg, yoga, tai-chi, qigong) as treatments of ADHD only four studies including a total of 83 participants met inclusion criteria for methodological rigor and size. Two studies evaluated mantra meditation and two studies compared yoga with conventional drugs, relaxation training, non-specific exercise or treatment as usual (i.e. stimulant medications and cognitive therapy). The authors reported that study design problems resulted in a high risk of bias in all studies and identified only one study that met criteria for formal analysis. In that small study (15 chlldren) the teacher rating ADHD scale failed to show significant outcome differences between the meditation group and the drug therapy group. The authors commented that small sample sizes of a few well designed studies and high risk of bias render current findings on meditation and mind-body techniques in the treatment of ADHD inconclusive.

Regular yoga practice may have an additive effect over medication alone

In a small pilot study ADHD children randomized to yoga experienced greater improvement over time compared to children who exercised. Children who continued on stimulants while practicing yoga experienced the greatest improvements. Two small controlled studies suggest that yoga and regular massage therapy may reduce the severity of ADHD symptoms.

Large well-designed studies are needed

Larger and better designed studies are needed to confirm beneficial effects of meditation and mind-body practices in individuals diagnosed with ADHD. To learn more about non-pharmacologic approaches to ADHD read my e-book ‘ADHD: The Integrative Mental Health Solution.”

The Effects of Dietary Modification on ADHD: A Concise Review

Inconsistent findings on food colorings and positive findings on highly restrictive diets

Many studies have investigated the effects of changes in diet on symptoms of ADHD. Research findings support that artificial food colorings do not contribute to ADHD however excluding food additives, sugar and certain food groups may reduce symptoms of hyperactivity in some cases.

Early studies on a restrictive diet that eliminates all processed foods reported promising findings in children with ADHD; however, a review of controlled studies failed to support these findings. Early studies suggested that artificial food colorings were associated with ADHD however a meta-analysis failed to confirm this. The oligoantigenic diet (OAD) is a highly restrictive multiple elimination diet that excludes food colorings and additives, in addition to dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts and chocolate. Oligoantigenic diets permit a limited number of hypoallergenic foods, like lamb, chicken, potatoes, rice, banana, apple, cabbage, broccoli, Brussels sprouts, carrots, peas, pears and cucumber, as well as salt, pepper, calcium, and some vitamins. Studies involve several phases and require many weeks to complete. During phase I, which typically lasts 4 weeks, specific food items are withheld from the diet and the patient is monitored using standardised symptom rating scales. In cases where symptoms improve during the initial treatment phase, specific foods are gradually re-introduced in phase II. A third phase follows a placebo-controlled crossover design in which the patient is randomized to a food item that initially caused symptoms or an acceptable placebo for 1 week, followed by a washout period, and subsequently exposed to either placebo or a specific food item or additive for an additional week. Several studies on the OAD regimen reported significant reductions in hyperactivity in children diagnosed with ADHD when specific food items were eliminated from the diet using the above protocol. In all of these studies behavioral symptoms improved during the elimination and placebo phases and recurred when children were subsequently challenged with the eliminated food item following a blinded protocol. A recent meta-analysis of studies on restrictive diets in childhood ADHD including 14 open studies and six controlled trials concluded that roughly 1/3 of hyperactive children may benefit from some form of an elimination diet.

Large well-designed studies are needed to confirm benefits of dietary modification

Although these results are promising they cannot be used to develop general ADHD treatment protocols because of study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high drop-out rates and, in some studies, non-blinded researchers. In the face of these promising findings the American Academy of Pediatrics does not endorse elimination diets because of inconsistent findings of efficacy and concerns that highly restrictive diets do not provide balanced nutrition. Parents who are considering restrictive diets should consult with a nutritionist and highly restrictive diets should not be continued longer than two weeks in the absence of noticeable improvements in ADHD symptoms.

To learn more about the role of nutrition and other non-pharmacologic treatments of ADHD read my e-book “Attention-Deficit Hyperactivity Disorder: The Integrative Mental Health Solution.”

Non-medication Therapies are Widely Used to Treat ADHD but Research Findings are Inconsistent

Many individuals diagnosed with ADHD use CAM therapies

Many individuals diagnosed with ADHD use alternative therapies alone or together with stimulants or other prescription medications. Growing concerns about inappropriate prescribing or over-prescribing by physicians of stimulant medications and incomplete understanding of risks associated with their long-term use have led to increasing acceptance of many complementary and alternative (CAM) therapies.

Surveys suggest that between 12 and 68% of children diagnosed with ADHD use CAM therapies largely out of parental concerns over safety of prescription medications. Over half of parents of children diagnosed with ADHD treat their children’s symptoms using one or more CAM therapies, including vitamins, dietary changes and expressive therapies, but few disclose this to their child’s pediatrician. However, when any herbal product or other natural supplement is used to treat ADHD it is regarded as the primary treatment over 80% of the time.

Uneven research findings support CAM treatments of ADHD

Most CAM therapies for ADHD are supported by limited research findings. However, a systematic review of clinical trials on herbal and nutritional interventions for ADHD found good support for zinc, iron, Pinus marinus (French maritime pine bark), and a Chinese herbal formula (Ningdong); and inconsistent findings for omega-3s, and l-acetyl carnitine. Limited findings from clinical trials on Bacopa monniera (brahmi) and Piper methysticum (kava) call for more research on these two herbals. The most appropriate CAM and integrative treatment strategies for ADHD depend on the subtype of ADHD that is being addressed, symptom severity, previous treatment outcomes using conventional pharmacologic treatments or CAM therapies, side effects, co-occurring psychiatric or medical problems, patient preferences, the availability of qualified CAM practitioners and access to reputable brands of specific natural supplements.

Future blog posts in this series will review the evidence for widely used CAM therapies used to treat ADHD. A concise review of non-pharmacologic CAM therapies used to treat symptoms of ADHD can be found in my e-book ‘Attention-deficit Hyperactivity Disorder: The Integrative Mental Health Solution.”

Medications Used to Treat ADHD: A Review

Pharmacologic treatments of ADHD

My previous post summarized the epidemiology, causes of ADHD. In this blog post, I review the efficacy and adverse effects of conventional pharmacologic treatments of ADHD. Subsequent posts will discuss the evidence for non-pharmacologic treatment strategies including natural supplements, EEG biofeedback, and others.

Stimulants: efficacy and adverse effects

Stimulant medications are the standard Western treatment of ADHD; however, serotonin-selective reuptake inhibitors (SSRI) and other antidepressants are also used with varying degrees of success. Extended-release forms of stimulants are better tolerated and less often lead to abuse. Rates of stimulant abuse may be especially high in individuals with comorbid conduct disorder or substance abuse. Stimulant use in these populations should be carefully monitored or avoided. Long-acting stimulants are associated with relatively less abuse because they cross the blood-brain barrier more gradually than immediate release stimulants. The recently introduced long-acting stimulant lisdexamfetamine dimesylate is a pro-drug with comparable efficacy to existing long-acting stimulants but with less abuse potential as it must be metabolized in the gut before being converted into the active drug d-amphetamine.

Approximately one-third of children and adolescents who take stimulants experience significant adverse effects, including abdominal pain, decreased appetite and insomnia, and 10% experience serious adverse effects. Because stimulants are classified as scheduled or restricted medications (depending on the country), prescriptions are usually limited to a short supply; this can result in treatment interruptions and transient symptomatic worsening when refills are not obtained on time. One-third of all individuals who take stimulants for ADHD report significant adverse effects, including insomnia, decreased appetite, and abdominal pain. Sporadic cases of stimulant-induced psychosis have been reported. Neurotoxic effects associated with long-term stimulant use have not been fully elucidated; however, chronic amphetamine use in childhood is associated with slowing in growth. Stimulants and other conventional treatments of adult ADHD may be only half as effective as they are in children. Only long-acting stimulants have been approved by the FDA for treatment of adult ADHD however short-acting stimulants are the most prescribed conventional treatments in this population.

Non-stimulant medications: efficacy and adverse effects

Controlled-release stimulants, buproprion, and the SSRI antidepressants are being increasingly used in the adult ADHD population; however, research findings suggest these medications may not be as efficacious as stimulants. Atomoxetine, a selective norepinephrine reuptake inhibitor (SNRI), is the only non-stimulant drug that has been approved by the FDA for adults diagnosed with ADHD. Atomoxetine has less potential for abuse but may not be as efficacious as stimulants. Atomoxetine is also FDA-approved for the treatment of childhood ADHD, however, there are growing concerns about its adverse effects, including hypertension, tachycardia, nausea and vomiting, liver toxicity and possibly increased suicide risk. In Australia, atomoxetine is registered for use by the Therapeutic Goods Administration. Other non-stimulant drugs recently approved by the FDA for treatment of childhood ADHD include modafinil, reboxetine and the α-2-adrenergic agonists clonidine and guanfacine.

In addition to conventional prescription medications, behavioral modification is a widely used conventional treatment of ADHD in children. Psychotherapy and psychosocial support help reduce the anxiety and feelings of loss of control that frequently accompany ADHD. Some findings support that cognitive-behavioral therapy (CBT) reduces symptom severity in adults diagnosed with ADHD.

To learn about non-pharmacologic treatments of ADHD check out my e-book “Attention Deficit Hyperactivity Disorder: The Integrative Mental Health Solution.”

Attention-Deficit Hyperactivity Disorder: A Concise Review

Attention-Deficit Hyperactivity Disorder: Epidemiology, Causes and Diagnosis

This is the first in a series of blog posts on ADHD. In it I concisely review the epidemiology, causes and diagnosis of this condition. Future blog posts will review the effectiveness and limitations of currently available mainstream treatments of ADHD, and research findings on a variety of complementary and alternative treatments being investigated.

Epidemiology of ADHD

Attention deficit hyperactivity disorder (ADHD) occurs in children and adults with roughly equal prevalence in all countries surveyed. Surveys suggest that 7 to 8 % of children and 4 to 5% of adults fulfill criteria for ADHD. The rate at which ADHD is diagnosed and treated in both children and adults has increased dramatically since the syndrome was first recognized as a specific disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 1970s. In the United States as many as 10% of males and 4% of females have been diagnosed with ADHD. An objective epidemiological or scientific basis for the rapidly increasing prevalence of ADHD in general and the higher incidence of the syndrome in boys compared to girls is highly controversial and may reflect social issues and changes in diagnostic criteria more than actual changes in prevalence rates.

ADHD has multiple causes

The causes of ADHD are multifactorial. Data from twin studies show that ADHD is a highly heritable disorder and the risk of developing this disorder is probably influenced by genes that affect CNS transport of dopamine and serotonin. ADHD is also associated with premature birth, birth trauma, childhood illness and environmental toxins. Increased risk of ADHD is associated with in-utero exposure to alcohol, tobacco smoke and lead. As many as 20% of ADHD cases may be caused by brain injury around the time of birth. While certain food preservatives exacerbate the symptoms of ADHD, they probably do not cause the disorder. Some cases of ADHD may be associated with delayed development of certain areas of the frontal and temporal lobes and relatively rapid maturation of motor areas of the brain. Neuroimaging studies suggest that these brain regions may have relatively decreased activation in individuals diagnosed with ADHD. Children diagnosed with ADHD frequently experience disturbed sleep including restlessness, sleep walking, night terrors and restless leg syndrome; however, a causal relationship between sleep disorders and ADHD has not been clearly established. Early childhood neglect or abuse may also increase the risk of developing ADHD. Most cases of ADHD probably result from multiple genetic, developmental, physiological, environmental and psychosocial factors.

Diagnosing ADHD

According to the DSM-5 a diagnosis of ADHD is considered to be a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. An ADHD diagnosis requires the presence of at least six symptoms (five for ages >17) of hyperactivity or inattention that begin before the age of 12, persist for at least 6 months, are maladaptive, inconsistent with the child’s development level, are present in tow or more settings, and are not better explained by a pre-existing medical or psychiatric disorder. Specific symptoms of inattention may include careless mistakes in schoolwork, difficulty sustaining attention in school-related tasks or play, failure to follow through with instructions, difficulty organizing tasks and activities, reluctance to engage in tasks requiring sustained attention, and being distracted easily by extraneous stimuli. Specific symptoms of hyperactivity or impulsivity may include fidgeting with hands or feet or squirming while sitting, frequently getting up in a classroom or other situation in which remaining seated is expected, running or moving in inappropriate or disruptive ways, or (in adults) subjective ‘feelings of restlessness’, difficulty engaging in quiet leisure activities and talking excessively.

Symptoms of inattention, impulsivity or hyperactivity must cause clinically significant impairment in at least two spheres including social, academic or occupational functioning. Neuropsychological testing is frequently employed to assess inattention, processing speed and neurocognitive deficits. A diagnosis of ADHD should be made in childhood only after other childhood disorders, including pervasive developmental disorders, learning disorders and anxiety disorders, have been ruled out. When evaluating adults a thorough medical history is important to rule out medical or psychiatric disorders that mimic symptoms or functional impairments that resemble ADHD. These include, for example, bipolar disorder, absence seizures, hypothyroidism, obsessive-compulsive disorder and chronic sleep deprivation.

The interested reader is referred to my ebook “Attention Deficit Hyperactivity Disorder: The Integrative Mental Health Solution” for a concise review of evidence-based non-pharmacologic approaches to this condition.

Mixed Findings on Acupuncture for Smoking, Addiction and Insomnia

Acupuncture is not effective for smoking cessation

Acupuncture is widely used to treat individuals who wish to stop smoking however findings of most controlled trials on acupuncture for smoking cessation have been negative or equivocal. Three meta-analyses of sham-controlled studies on the efficacy of acupuncture for smoking cessation (2,000 total subjects) concluded that therapeutic acupuncture protocols and sham acupuncture have equivalent efficacy, suggesting a significant placebo effect. Longer sham-controlled studies are needed to determine whether more frequent acupuncture treatment following a specific protocol or a greater number of total treatments is effective for smoking cessation.

Acupuncture is not effective for reducing symptoms of nicotine withdrawal or cocaine addiction but may reduce cocaine craving after abstinence is achieved

Two systematic reviews of sham-controlled trials concluded that both conventional acupuncture and electro-acupuncture are equally ineffective in reducing symptoms of nicotine withdrawal and controlling cocaine addiction. A large study examining three auricular acupuncture protocols (i.e. a technique in which small needles or ‘seeds’ are applied to the ear) for relapse prevention in narcotics abusers concluded that all three protocols were associated with reductions in drug use over time. An 8-week randomized sham-controlled study (32 subjects) compared acupuncture with two prescription medications used for craving reduction versus placebo in cocaine addicts on methadone maintenance therapy. Half of the subjects dropped out however almost 90 percent of those who completed the study achieved abstinence by the end of the study. Patients who achieved abstinence reported diminished craving and significantly improved mood.

Acupuncture may be beneficial for insomnia in individuals with schizophrenia or anxiety disorders

The absence of standardized acupuncture treatment protocols for insomnia has interfered with efforts to design rigorously controlled double-blind studies. A systematic review of all studies on acupuncture for insomnia published in the English language through 2002 identified few studies for analysis because most studies had not employed randomized, double-blind procedures. Acupuncture may be beneficial for insomnia associated with generalized anxiety and schizophrenia. In a large-case series (500 subjects), schizophrenics reported significant improvements in sleep following acupuncture treatments. In a small sham-controlled trial (40 subjects), patients complaining of insomnia were diagnosed using Chinese medical assessment methods and randomized to an acupuncture protocol addressing the specific energetic “imbalance” underlying their sleep disturbance versus a sham acupuncture protocol. Significant and sustained improvements in the subjective quality of sleep and changes on EEG recordings during sleep reflecting normalization of sleep were found in the treatment group but not in the sham group.

Acupuncture is generally safe but there are rare reports of serious complications

Uncommon transient adverse effects associated with acupuncture include bruising, fatigue, and nausea. Infrequent cases of infection with human immunodeficiency virus (HIV), hepatitis B, and hepatitis C have been reported when non-sterilized needles are used. Rare cases of serious medical complications such as pneumothorax and cardiac tamponade have been reported as a result of accidental puncturing of the lungs or the pericardium.

Final words

Acupuncture is not effective for smoking cessation or reducing symptoms of nicotine or cocaine withdrawal but may reduce cocaine craving following withdrawal. Acupuncture is probably an effective treatment of insomnia in individuals diagnosed with schizophrenia or anxiety disorders, however studies need to be done in the general population to confirm general beneficial effects on insomnia.

Transcranial Direct Current Stimulation (tDCS) for Depressed Mood

Introduction

Transcranial direct current stimulation (tDCS) also called microcurrent electrical stimulation or cranioelectrotherapy stimulation (CES), is a technique that applies extremely weak electrical current to the head and neck to treat mental health problems. In a recent blog post I briefly reviewed the evidence for tDCS as a treatment of anxiety, substance abuse and insomnia. This entry is offered as a concise review of the evidence for tDCS for treating depressed mood

How (we think…) it works

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that applies weak direct current (typically 1 to 2 milli-Amps) to the brain via electrodes placed on the scalp resulting in hyperpolarization or depolarization of underlying neural tissue causing beneficial changes in neurotransmitter receptor function or stimulating synaptic plasticity and neuronal remodeling. TDCS is being investigated as a treatment of depressed mood based on the theory that the application of very weak electrical currents to certain brain regions may have beneficial effects on brain circuits involved in attention, perception, learning and memory that affect mood. This hypothesis is consistent with findings of abnormal cognitive processing in major depressive disorder, bipolar disorder and other psychiatric disorders. Research findings suggest that problems in affective and cognitive processing are related to functional abnormalities in networks linking specific brain regions including the hippocampus, amygdala and prefrontal cortex. It has been suggested that changes in cortical excitability caused by tDCS may last longer than changes induced by transcranial magnetic stimulation, while offering the advantages of portability and fewer adverse effects.

Studies on tDCS in depressed mood

Findings of small sham-controlled studies suggest that antidepressant effects of tDCS are related to changes in affective processing. Limited research findings support that tDCS may have beneficial synergistic effects when combined with antidepressants and that combined treatment might be more effective than medications or tDCS alone. TDCS should be viewed as a promising emerging treatment of depressed mood pending confirmation by large sham-controlled studies. It is important to comment that findings of studies on tDCS for depressed mood are limited by small study size, heterogeneity in outcomes measures and reporting bias resulting in underreporting of non-significant findings.

Few safety problems

Few mild transient adverse effects of tDCS have been reported including burning, itching and tingling sensations at the site of electrode placement.

Acupuncture in Mental Health Care: A Concise Review

Challenges in acupuncture research

Acupuncture is widely used in Asian and Western countries to treat diverse mental health problems. Evaluating the clinical efficacy of acupuncture in depressed mood and other mental health problems poses many methodological challenges because of differences in the severity and comorbidity of mental, emotional, and physical symptoms in study populations; concurrent use of other conventional or CAM treatments; conceptual differences between Chinese medicine and biomedical diagnoses; and the use of individualized acupuncture treatment protocols reflecting the patient’s “energetic” balance. This post concisely reviews the evidence for acupuncture as a treatment of depressed mood, anxiety, post-traumatic stress disorder (PTSD) and alcohol abuse. A subsequent post will review the evidence base for acupuncture for smoking cessation, narcotic abuse and insomnia.

Electroacupuncture may have superior efficacy compared to conventional acupunture

Sham-controlled studies suggest that conventional needle acupuncture, electroacupuncture, and computer-controlled electroacupuncture (CCEA) have consistent beneficial effects on depressed mood. Findings of a double-blind, sham-controlled study support that traditional manual acupuncture (i.e., needles in the absence of electrical current) is an effective treatment of severe depressed mood. By the end of the 8-week study, 68 percent of 33 female outpatients being treated with a specialized acupuncture protocol directed at depressed mood had achieved full remission. However, matched depressed women in a wait-list group showed equivalent improvement. In a large 6-week, multicenter study (241 subjects) depressed inpatients randomized to receive electroacupuncture plus placebo versus electroacupuncture plus the antidepressant amitriptyline experienced equivalent improvements in mood. Electroacupuncture was superior to amitriptyline in patients who did not report comorbid anxiety. Patients treated with electroacupuncture had significantly elevated plasma norepinephrine concentrations following a 6-week course of treatment, suggesting that the mechanism of action of electroacupuncture involves stimulation of norepinephrine release.

Findings inconclusive pending confirmation by improved study designs

CCEA uses computer-guided modulation of the frequency and waveform of electrical current delivered through acupuncture needles. Preliminary findings suggest that high frequencies (up to 1,000 Hz) yield responses in depressed patients that may be superior to both conventional acupuncture and electroacupuncture. A narrative review of controlled studies, outcomes studies, and published case reports on acupuncture as a treatment of anxiety and depressed mood supported that sham-controlled studies yielded consistent improvements in anxiety using both regular acupuncture and electroacupuncture. Research findings on acupuncture in depressed mood and anxiety should be regarded as inconclusive because of methodological flaws including the absence of standardized symptom rating scales in most studies, limited follow-up, and poorly defined differences between protocols used in different studies.

A review of prospective trials on acupuncture as a treatment of post-traumatic stress disorder (PTSD) identified four quality sham-controlled studies and two quality uncontrolled trials that met inclusion criteria. One high-quality trial included in the review showed statistically significant differences between the acupuncture and wait-list group but non-significant differences between the acupuncture and individuals receiving cognitive-behavioral therapy (CBT). Patients receiving acupuncture or CBT continued to report clinical improvements in PTSD symptoms 3 months after study endpoint. These findings are limited by the small number of trials that met inclusion criteria (only one study reviewed was included in the analysis), the absence of sham-controlled studies, the use of different study designs across trials examined, and poor methodological quality of many studies.

Inconsistent findings for acupuncture in relapse prevention

Research findings on acupuncture for relapse prevention in alcohol abuse are inconsistent, reflecting differences in the selection of acupuncture points, the treatment protocol used (i.e., conventional vs. electroacupuncture), frequency of treatments, the duration of total treatment, and the relative skill or specialized training of practitioners. Positive findings of two controlled trials supported the hypothesis that specific acupuncture protocols significantly reduced alcohol craving and reduced relapse rate in recovering alcoholics. However, a subsequent randomized controlled trial found no significant differences in craving or relapse rates between an acupuncture protocol traditionally used to treat addiction, sham transdermal stimulation on random points, and a wait-listed group.