TCPR: Dr. Mischoulon, thank you for returning to the pages of The Carlat Psychiatry Report. I know that since our last interview, you have been involved in studying the use of acupuncture in psychiatry. Tell us about that.
Dr. Mischoulon: We are currently starting an acupuncture program for the treatment of depression at Massachusetts General Hospital (MGH).
TCPR: Have you trained in acupuncture?
Dr. Mischoulon: Yes, my colleague Albert Yeung and I both trained in 2004 at the Helms Medical Institute, which is affiliated with UCLA. Your readers might be interested to know that if you are a licensed physician, you need only 300 hours of acupuncture training to be accredited in most states to practice.
TCPR: How much does this training cost?
Dr. Mischoulon: Between six and seven thousand dollars for 300 hours of training. Residents and fellows can get discounted rates at many programs.
TCPR: And why did you choose the Helms Medical Institute for your training?
Dr. Mischoulon: This program is geared specifically to licensed physicians, and it is the one most grounded in medicine. Dr. Helms talks a lot about the physiological basis for how acupuncture works and why acupuncture points are useful. You also learn about the Chinese theory behind it, and you are taught basically how to do the needle techniques and how to conceptualize illness within the Chinese medicine framework.
TCPR: Has acupuncture been studied much for depression?
Dr. Mischoulon: No, in fact depression is one of the least-studied areas as far as acupuncture goes, probably because during the time when acupuncture was developed there was a lot of stigma attached to mental illness, which was often viewed as madness. Our hope is to start an acupuncture practice at MGH and then to do some studies looking at acupuncture as augmentation. For example, for partial responders to SSRIs, we will add some acupuncture and see if that helps.
TCPR: You mentioned that there really is not a lot of good research on depression. Tell us a little bit about what the medical community considers acupuncture to be fairly well established for.
Dr. Mischoulon: Pain is the most common indication for acupuncture–particularly back pain and headache–but even in that arena there have not been a lot of good studies. The problem is that it is very hard to do double-blind controlled studies. The reason is that it is difficult to develop a placebo in acupuncture. Some researchers have used “sham acupuncture” as a placebo, which usually entails putting the needles in points that are thought not to be relevant to the problem that they are treating. The problem is that there is a very high response rate to sham acupuncture. Another problem is that there are different schools of acupuncture, including the Chinese school, the Japanese school, the French school, and the Korean school. Since acupuncturists do research using their particular system, it can be difficult to generalize from one study to another, making it difficult to interpret the literature.
TCPR: Is there enough literature on acupuncture for pain to be convincing, in your opinion?
Dr. Mischoulon: There are dozens of small studies of acupuncture for different types of pain, and taken together, they all suggest that there is some benefit. There are more published studies, but most are in Chinese and have not been translated into English.
TCPR: And what is thought to be the mechanism for pain relief in acupuncture?
Dr. Mischoulon: Studies have shown that by needling specific points, you can release endorphins, so that has been one of the proposed mechanisms of action. To the best of my knowledge, no human studies have compared true and “sham” acupuncture points for endorphin release.
TCPR: And what is the traditional Chinese medicine theory of the mechanism?
Dr. Mischoulon: The Chinese system says that we all have this vital energy called qi (pronounced “chee”), which runs throughout everybody’s body. This energy is replenished in part through the food we eat, and we use it in the course of our activities of the day. And if there is some sort of imbalance in the qi, that is, if you have too much or too little, that results in disease. So the idea is that by using this intervention with the needles you refit the balance of the qi in the body and that is essentially what corrects the disease process.
TCPR: What does Western medicine have to say about this theory? Have there been any studies done that might connect qi to things we can measure with scientific instruments?
Dr. Mischoulon: Yes, there have been some physiologic studies that suggest that when you insert a metal needle into the skin it creates an electrical imbalance, and by putting several needles into the patient along “meridians” you cause electrons to flow through the tissue. It is theorized that this electron flow is what results in the therapeutic effect by releasing endorphins or neurotransmitters in some way.
TCPR: You mentioned meridians. What are they?
Dr. Mischoulon: Each meridian is a longitudinal axis that corresponds to a particular organ. For example, there is a liver meridian, a kidney meridian, and a heart meridian. Now, when you are talking about these organs in Chinese medicine, they are not necessarily meant to be taken literally. So, for example, if you have a problem in the kidney meridian, it does not necessarily mean that you have kidney disease per se. In traditional Chinese medicine the kidney is said to store most of the vital energy, or qi, so a problem with the kidney meridian could indicate that there is a qi imbalance in the kidney, and so by needling that particular meridian you would reverse the problem.
TCPR: Is there any scientific evidence that meridians exist?
Dr. Mischoulon: There is suggestive evidence. For example, with regard to the points themselves, one very interesting finding is that those specific points called “acupuncture points” actually have a very high concentration of nerve tissue, lymphatic tissue, and blood vessels. One study showed that acupuncture points actually conduct electricity through the skin a lot more readily than other areas of the skin that do not correspond to traditional acupuncture points.
TCPR: Aside from pain, what else does acupuncture seem to be helpful for?
Dr. Mischoulon: It is used a lot for substance abuse, particularly for smoking cessation. This is a very popular use of acupuncture because most addiction problems can be treated by using points in the ear, which means it is a very efficient way to deliver treatment. You can have a whole clinic of people in one room sitting and receiving the needles in the ear. They don’t have to get undressed, and they don’t have to lie down on the table.
TCPR: Does the ear correspond to a “brain” meridian?
Dr. Mischoulon: Not exactly–acupuncture of the ear is a school unto itself. Basically, the ear is said to correspond to a homunculus where the head would be at the bottom of the ear and the feet near the top. So, imagine looking at an ear straight on, and then imagine an upside-down person in it. The ear has different points corresponding to different organs, and there are also some “master ear points” that are used for general functions of the body, such as stress control. So, specific points on the ear can be used to treat anxiety and addiction.
TCPR: And how effective is that?
Dr. Mischoulon: Well, again, the literature gives mixed results. In some studies there appears to be a response; in others there isn’t. And again most of the studies tend to be very small and don’t have really adequate sample sizes to have enough statistical power.
TCPR: Acupuncture certainly sounds intriguing, but with all the limitations on the data, how would you recommend that we practicing psychiatrists view this?
Dr. Mischoulon: At this point I still consider it an experimental treatment, since we don’t have a lot of data to support it yet. But I think the potential candidates for acupuncture would be people who have had trouble with medications: either they haven’t responded or they have had a lot of side effects. Other appropriate candidates would be people who have relatively mild illness and have a particular interest in trying acupuncture as an alternative to medication. One of the nice things about acupuncture is that it is very safe–there are very few reports of serious adverse effects from it. So the worst that could happen is that the treatment doesn’t work – a financial risk, but not really a medical one if it’s used adjunctively or in mild cases.
TCPR: What about acupressure? Is it similar to acupuncture?
Dr. Mischoulon: Yes, it uses the same principle. Acupressure works using the same points except that you just press on them instead of using the needles. Japanese shiatsu massage is a form of acupressure. However, the data for acupressure is even scanter than for standard acupuncture, so it is very hard to really comment on whether acupressure would be as satisfactory as acupuncture for treatment of anything.
TCPR: I know people who go to their acupuncturist for sort of a “tuneup,” meaning that they feel that it just increases their overall energy and vitality.
Dr. Mischoulon: Yes, that’s common, and in general, most acupuncturists will recommend that people have maintenance treatment after they have been cured of whatever their problems were because they often consider these problems to be lifestyle related.
TCPR: Does insurance cover these treatments?
Dr. Mischoulon: Insurance is starting to cover acupuncture, but, as with psychotherapy, most plans only cover a certain number of visits. And oftentimes acupuncture treatments require visits two or three times a week or more, and then maintenance may be required. So a lot of people have to pay out of pocket. The good news is that acupuncture is relatively affordable: an acupuncture session, for example, might cost you around $70.