1) Climacteric (the journal) has only been around since 1998. Not necessarily a bad thing but could mean it is a shady journal.

2) Impact factor 1.98. Also not necessarily bad, could bu just because it is new. Or because nobody cites it for a good reason.

3) The selection criteria basically was for perfectly healthy post-menopausal women aged 50-67

4) groups were acupuncture and sham acupuncture (which they call “placebo”)

5) Twice a week for 5 weeks

6) They say ther were double blinded but they didn’t say how and their phrasing was odd:

“Neither the researchers nor the participants knew which patients had received the sham acupuncture and which had received the actual acupuncture, to prevent bias on the part of the researchers and the volunteers.”

I mean it is correct, but I don’t recall reading a paper that told me why we double blind. I know why we double blind, you know what I mean? Just struck me as odd is all.

7) They started with a pool of 102 but only 18 met DSM-IV insomnia criteria so that was the study size.

8) Once again some wierd phrasing:

“At baseline, the two groups were not significantly different in anthropometric characteristics such as BMI and age. There were no differences between the variables of age and BMI when comparing the two groups, showing comparative viability between the acupuncture”

9) It seems that they demonstrated improvement in each group from baseline but no difference between the groups. In other words they intervention they themselves call “placebo” worked in exactly the same way as the actual acupuncture (I know, shocking right?).

“The acupuncture group showed a significant improvement in the PSQI questionnaire when baseline and final evaluation were compared (12.77 ± 0.7 vs. 9.77 ± 0.8, respectively; p < 0.01; effect size = 0.8) and an enhancement of the psychological WHOQOL (57.07 ± 4.1 vs. 66.67 ± 3.1, respectively; p = 0.03; effect size = 0.66)"

"The comparison between groups after treatment showed no differences among questionnaires, but the comparison did show a trend toward improvement in PSQI in the acupuncture group (9.77 ± 0.8 vs. 12 ± 0.9; p = 0.058; effect size = 0.45).”

And also it is funny that they mention the psychological WHOQOL as getting better. I wonder why they didn’t mention that they were looking at 6 comparisons and only that one showed improvement, and that in the sham group the social WHOQOL improved as did the environmental WHOQOL?

So in other words, no difference between “treatment” and “placebo” but somehow the placebo actually had more positive effect than the treatment!. 2/6 vs 1/6 metrics improved. The “placebo” also had improvements in sleep latency. They had another 8 measurements they were looking at, of which “treatment” improved on one, maybe two.

So we have 14 endpoints they are separately analyzing on a group of 18 people, with both placebo and treatment showing improvement over time, but no difference between the two groups, and in fact placebo outperforming (a bit) the treatment group.

Sounds like a resounding endorsement of acupuncture to me! After all, in the words of the authors:

“Acupuncture intervention produced a significant improvement in subjective sleep quality, as evaluated by the psychological WHOQOL and sleep quality indicated by the PSQI at the final evaluation. This finding suggests that the acupuncture treatment was effective for treating insomnia, as suggested in other studies that showed an improvement in sleep quality through acupuncture by different types of evaluations, such as melatonin secretion and nocturnal hot flushes”

Clearly that is what the study showed, after all.

They even say that their study is just like others that have shown:

“A systematic review of randomized, controlled trials using meta-analyses to study acupuncture for the treatment of insomnia31 showed a beneficial effect of acupuncture compared to no treatment and of real acupressure compared with sham acupressure on total PSQI scores.”

Wait, I thought we were talking about acupuncture, not pressure. Oh well, must be the same thing. And yes, clearly this study showed us that “real” vs “sham” acupuncture was so much better.

I’ll let the authors have the last words:

“Based on the results of this randomized, controlled-trial study, we conclude that acupuncture is effective in improving the quality of sleep and the psychological domain of quality of life in postmenopausal women with insomnia. Furthermore, we observed an important decrease in subjective insomnia supported by a high effect size.”

http://www.ncbi.nlm.nih.gov/pubmed/22943846

“Acupuncture improves sleep in postmenopause in a randomized, double-blind, placebo-controlled study.”

Conclusion: “Acupuncture was effective in improving reported sleep quality and quality of life in postmenopausal women with insomnia.”

Judging from the abstract, it seems to me that the conclusion is not reasonable. They found an improvement in ONE metric, in a small study of 18 patients overall.

And also they say:
“Comparison of baseline and post-treatment data of the acupuncture group showed that treatment resulted in significantly lower scores on the Pittsburgh Questionnaire and an improvement in psychological WHOQOL.”

Meaning the test subjects “improved” after treatment – that’s really astounding. And no word on comparing the improvement to the control group.
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Posted the above to topic suggestions on Neurologica, and thought I might post it to a recent SBM text on acupuncture as well.

And of course xplodynowcow – very succinct and also quite in line with my own thoughts, so thanks to you as well. I’ll be using that analogy from now on though I hope you’ll understand if I don’t credit you every time

It’s not because psychiatric disorders have anything to do with a primary dysfunction of neurotransmitter signaling, i.e. a “chemical imbalance” or anything like that. It’s that creating artificial chemical imbalances can actually induce or relieve the symptoms by changing the firing patterns.

This is a perspective I hadn’t actively thought of and actually helps me quite a bit, so thank you again. I had an argument with someone online many moons ago about it and had I thought of this perspective I think we may not have argued as much. However, it will help me with a new frame through which to look at future learnings on the topic (not my only frame, but merely another way to look at things as I synthesize my ongoing analyses and thoughts as I continue my learning).

I am not interested in pursuin a career in psychiatry, but I do find the field interesting, overly and unreasonably maligned, and genuinely an area of medicine with significant promise for expansions and becoming more robust as our technological sophistication grows along with our corpus of knowledge.

Thanks again for taking the time to post!

@nybgrus: I agree with you, and I would actually take it several steps further. It’s a slow moonlighting shift, so prepare for a rant.

Depression, even major depressive disorder as formally defined by the DSM, is a grouping of several distinct clinical syndromes that most likely has a large number of different etiologies, possibly even hundreds or thousands. And that’s not including bipolar depression, which often resembles the “atypical” subtype of depression but can also have mixed manic or hypomanic features, or the “depression”/dysphoria associated with borderline personality disorder (for example). The fact that these different subtypes of “depression” respond differently to different classes of medication indicates that they have different etiologies, but ultimately nobody knows.

Psychiatry is the only field left in medicine where all diagnosis and treatment is still based on clinical exam. This means that everything that psychiatrists treat is a syndrome rather than a clearly-defined disorder, with the exception of some types of mental retardation like Rett Syndrome that now have identified causes. I use the word “disorder” because that’s the terminology used in the field, but it’s more technically accurate to call them syndromes.

The only reason that it’s even possible for psychiatry to exist and maintain a surprisingly high degree of efficacy in the face of minimal knowledge of the actual pathophysiology is because different patients have such a high degree of similarity in their symptoms, which allows us to categorize people and find and validate treatments empirically. In my opinion, “depression” is the syndrome with the highest degree of clinical heterogeneity, more so than psychotic disorders, anxiety disorders, OCD (which falls between tic disorders and anxiety disorders), addiction, etc. I suppose you could say that “personality disorders” as a group are more heterogeneous.

Anyway, my opinion on the matter is that the major syndromes recognized by adult psychiatry (child psych is different) correspond to distinct failure modes of brain homeostasis. Depression is one type of broken state that the brain can fall into, just like addiction, anxiety, mania, psychosis, etc. We know how to induce states in humans, or at least animals, that are very similar to the primary disorders, which suggests that there is a surprisingly small number of ways the brain can break, and there are a large number of insults that can cause the brain to break down along one of those paths. For example, prolonged sleep deprivation causes depression in many people. If you lock a person up in a room long enough with a cocaine self-administration button, you could make them an addict (it works with rats). High doses of stimulants produce a state very similar to mania, including the psychosis that eventually results. This can be used as a model of psychosis itself, while psychosis plus the other two major symptom clusters of schizophrenia can be generated using NMDA antagonists like PCP.

At the end of the day, psychiatric disorders are just abnormal patterns of action potentials that the brain is unable to restore to a normal state, exactly analogous to cardiac dysrhythmias. And just like cardiac dysrhythmias, all we have to do to fix the problem is to restore the normal activity patterns, or at least a less abnormal activity pattern that is grossly compatible with normal physiological function. In the heart, there are dysrhythmias that we can’t fix, but we can lesion the conduction pathways and pace the ventricles, and the patient’s fine. In the brain, it’s more complicated. However, in either the heart or the brain, if fixing the activity patterns required us to actually understand the underlying pathophysiology fully or to manipulate each cell individually to restore normal activity patterns manually, it would be completely hopeless. Fortunately, we don’t actually have to do those things most of the time – all we have to do is bump things in the right direction enough to allow brain (or heart) homeostasis to fix things. That’s why psychiatrists can prescribe drugs with incredibly broad action across multiple parts of the nervous system and still get therapeutic effects. It’s not because psychiatric disorders have anything to do with a primary dysfunction of neurotransmitter signaling, i.e. a “chemical imbalance” or anything like that. It’s that creating artificial chemical imbalances can actually induce or relieve the symptoms by changing the firing patterns.

“Depression” is too broad a term used too casually in too many contexts. Clearly, what rambly-troll-guy referred to as “depression” can be resolved through lifestyle changes. But what about those with a depression that doesn’t respond to treatment, pharmacological and otherwise?

How this condition (depression) has become a ‘medical’ problem and not a socialogical problem is beyond belief to me.

Maybe because the brain is an organ and can malfunction just like any other organ in your body? Got type 1 diabetes? You don’t get better friends and a happier job so that your immune system decides to stop attacking beta cells in your pancreas; you take insulin injections. Got a mood disorder? Well, medical science is still figuring that one out.

Not sure how much you have seen or paid attention to my writings on the matter, but in a quick nutshell I have come to think of “depression” as a clinical syndrome that has at least 2 or 3 quite separate etiologies (neurotransmitter, neural pathway, and specific neural nuclei issues) that is a continuum and we simply do not have the technological or clinical sophistication to resolve the different etiologies, but the end result is a clinical picture we call “depression.”

Obviously a lot of nuance missing there, but I figured I would ask you specifically – does that seem like at least a sort of reasonable idea?

There are generally established standards for meta-analyses and systematic reviews. Why do you feel that you can flaunt them? Do you really believe you are inventing new methods of integrating data from diverse studies? Do you realize, that if your method of integration work, we would not even need randomized trials?

You are a true huckster, trying to pass off opinions as if they were based on a systematic review.

Having said, I would assert that the methods are a means and not the end. I would be hard pressed to accept that the data about the relative ease with which some depressives improve in a particular episode (up to 30%) is due to methodological flaws. In fact, focusing on methodological flaws lets you opt out of the real issue that over 50% of depressives don’t do well with the most relatively benign treatments, excluding treatments such as ECT, TMS, VNS or complicated pharmacotherapies.

Hence, the second point, that whatever we are dealing with is not entirely due to measurement problems. If we truly develop a ‘penicillin’ for depression, all this discussion about methods becomes mute, as the primafacie evidence would be simple enough.

So, focusing on the methods of measurement doesn’t lead to better therapeutic results. On the other hand, methods are simply a means to reveal false claims and to discourage shysters that sometimes disguise themselves as genuine advocates of help and hope for the depressed folks.

Thus, something more in the nature of understanding the disease and better treatments to be developed, while not being fooled by shysters, either by false criticisms and false claims.

the theory says that a depressed person, with guidance from a counselor, can learn to identify these, can evaluate how they are unreaslistic, and can challenge these, and start thinking differently. if the depressed person starts perceving things in a less depressogenic way, they will start getting better.

there is more, but this is enough to answer the question.

decades ago, psychologists figured this out. And developed measures of this suspected phenomenon. Attributional Style Questionnaire is probably the leading one. we psychologists pretty much dominate the field of the science of measurement when it comes to difficult-to-measure phenomena – psychometrics. we have this one down pretty good. go read nunnallly. there is no scam or game. everything has to be on the up-and-up, replicable, etc.

If certain cogntive attributions are what is going on with depressed ppl, then you should see certain scores in depressed ppl, and different scores in non-depressed ppl. this is what they found.

also, as ppl get less depressed, the scores should change. this is what they found.

if a counselor strives to help a person change these thoughts, then depression should be relieved. this is what they found.

So, there is theory, and observed evidence that matches. and, the phenomena can be manipulated and predicted outcomes happen.

go google the ASQ.

In contrast, acupuncture posits that there is this life force flowing around in the body. it generally flows around in some certain way. illness results from it flowing in the wrong way somewhere or somehow.

Jshiner: you find me some reasonable, reliable measure of this life force.

you show me where clinical predictions match its quantity or value.

you show me where acupuncture is predicted to change it one way, a priori, then does.

show me replicability.

basically, you cannot.

at one point in time, in the 1970s, maybe the science of psychotherapy was somewhere close to the science of acupuncture. the practice surely was not that far off.

but we have been earnestly scientifically studying this since Eysenck criticized the practice of psychological counseling way back in the 1950s, pointing out we had no evidence of efficacy compared to doing nothing.

that kick in the pants got us rolling. by the 1970s, we had demonstrated efficacy of psychotherapy for depression. by the 1980s we were showing why/how.

the acupuncture people don’t have this. any of it. they have answers, but no measures, no studies, no supported predictions. they have nothing ruling out various likely biases such as expectancy effects and ‘non-specific therapeutic factors.’

that is what is different between acupuncture research and psychotherapy research.

there is no recognized

dirk – print out this discussion, go to a decent therapist, and say, ‘here is part of my problem – i don’t have the ability to recognize it yet – please help me.’

I believe what you are referring to is called “making $hit up” which is perfectly within the purview of acupuncturists since that is what they are doing to begin with.

I can see how an acupuncturist would certainly have more degrees of freedom in making things up to change therapy than a psychotherapist would.

I believe Dr. Coyne would say (well at least I would, and I think he would agree) that these changes in acupuncture aren’t really changing the actual therapy provided whereas in psychotherapy it is.

However, it is a valid point that the perception of change from the patient’s perspective, as told by the believing acupuncturist, could be indistinguishable from the valid evidence based changes of psychotherapy.

Whether this actually changes the outcome (i.e. would someone not responding to “traditional” acupuncture actually respond to such a “change” in the acupuncture regimen) is, to the best of my knowledge unanswerable with data at this time. I think it would not, on the average, change outcomes significantly (clinically at least, statistically possibly) but that is inference. A robust answer to that question would indeed by quite enlightening.

Thanks for your reply. I want to clarify as well that my first paragraph in my prior post was in regard to Dirk’s postings.

I am trying to challenge your notion that 1) because you can think of proposed mechanisms for change that are assumed in evidence supported psychotherapies, allowing therapists to try a emphasize a different proposed mechanism of treatment benefit (ex. for CBT, switching from challenging distorted cognitions to behavioral activation), but 2) because you can’t think a proposed action for acupuncture, acupuncturists can’t make changes to treatment based on treatment response.

I am advancing that while assume effect of proposed mechanism of change after we see positive outcomes, good outcomes do not mean our proposed mechanism of change is accurate. Because of this, I offered that many acupuncturists can describe a proposed mechanism of how their treatment will be effective for patients, and use understanding of that mechamism/theory to engage with patients in responsive ways.

I am not denying that the studies on acupuncture for depression are not good quality and that there are no head-to-head studies with psychotherapies included. I am not denying this or advancing that acupuncture is an evidence supported treatment for depression. However, I think you left yourself weak in a argument in trying to make a distinction between the two treatments in that one has a mechanism for change and one doesn’t. I would propose that both can have active and (interally) consistent theories of change (regardless of the extent of helpfulness treatments impoart), and that the effectiveness of the treatments do not validate the proposed theory of change in themselves.

First, acupuncturists may well believe in their approach and the patients also, but belief is not enough to obtain results. The expectation that it is sufficient, is based on an understanding of results obtained in placebo conditions in clinical trials. These conditions do not simply reflect effects of belief, whether of practitioners or patients, but the sum total of background factors at work in a trial, including attention and support, ritual, or whatever.

Second, the larger acupuncture for depression literature has been shown in a number of reviews to be of exceedingly poor quality, with a strong confirmatory bias. Khan/Kirsch only picked out five studies that even their authors considered exploratory or preliminary. This is hardly the basis for the judgments that Khan/Kirsch made.

None of the studies selected by Khan/Kirsch involve head-to-head comparisons of acupuncture versus antidepressants or psychotherapy. They relied on voodoo statistics to make comparisons.

Psychotherapies on the other hand are manualized and the studies in which the therapies of validated allow therapists to improvise within the limits of these manuals.