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Acupuncture for Psychiatric Illness: A Literature Review

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 Acupuncture for Psychiatric Illness:
A Literature Review
Noah Samuels, MD; Cornelius Gropp, MD; Shepherd Roee Singer, MD; Menachem Oberbaum, MD

The use of complementary and alternative medicine (CAM) is on the rise,

especially among psychiatric patients. Acupuncture is considered a safe and
effective treatment modality, and traditional Chinese medicine teaches that
acupuncture harmonizes the body’s energies. Scientific research has found
that acupuncture increases a number of central nervous system hormones
(ACTH, beta-endorphins, serotonin, and noradrenaline) and urinary levels of
MHPG-sulfate, an adrenergic metabolite inversely related to the severity of
illness in schizophrenics. Acupuncture can have positive effects on depression
and anxiety, although evidence is still lacking as to its true efficacy for these
conditions. To the authors’ knowledge, no trials have been conducted for
schizophrenia, and researchers evaluating acupuncture in cases of substance
abuse have found conflicting results. Further research is warranted.
Index Terms: acupuncture, anxiety, depression, schizophrenia, substance abuse

The use of complementary and alternative medicine (CAM)
is on the rise,1,2 with psychiatric patients, especially those
diagnosed with disorders such as anxiety or depression,
more likely to use CAM than are patients with nonpsychi-
atric illness.3,4 The ancient Chinese treatment of acupunc-
ture incorporates the use of ultra-fine needles (diameter
0.15–0.30 mm), which are inserted into specific points on
the skin (acupoints). Acupuncture is central to the treatment
regimen of traditional Chinese medicine (TCM), along with
other manual therapies (eg, Tui Na, Chi Gong), herbal rem-
edies, and nutritional and lifestyle changes. TCM promotes
a holistic, energy-based approach to well-being, as opposed
to the disease-oriented approach of Western (scientific)
medicine. Both the US National Institutes of Health and
British Medical Association recognize acupuncture as an
Drs Samuels, Singer, and Oberbaum are with the The Center
for Integrative Complementary Medicine in Jerusalem, Israel. Dr
Gropp is with Psychiatric Consultation and Liaison Service at
Shaare Zedek Medical Center in Jerusalem.
Copyright © 2008 Heldref Publications
effective treatment for many medical conditions,5,6 although
for many in the medical profession, acupuncture and other
CAM treatments remain enigmatic.
According to TCM, the body’s energy, or Qi (pronounced
chee), flows along series of points called meridians. Each
of the internal organs has a corresponding meridian, and
applying pressure (acupressure, Shiatsu), heat (Moxibus-
tion), or needles (acupuncture) to relevant acupoints is
believed to influence each of the internal organs and harmo-
nize the body’s Qi. There are many schools of acupuncture
(eg, Chinese, Japanese, Korean, Indian), each with its own
approach to diagnosis and allocation of acupoints. Modern
acupuncture has branched out into related fields, such as
electroacupuncture (low-voltage stimulation of needles)
and laser acupuncture. Auricular acupuncture is a related
field in which needles are inserted into points located on
and around the earlobe that correspond to internal organs.
TCM teaches that Qi exists in many forms in the human
body. For example, Jing—considered the most concrete
form of Qi—is housed in the kidneys. Levels of Jing
increase and decrease in 7-year cycles in women in a

55
ACUPUNCTURE FOR PSYCHIATRIC ILLNESS
circadian fashion that is similar to levels of estradiol in the
fertility cycle. Shen (meaning “of the mind”) is the most
spiritual form of energy and is housed in the heart. Shen
is responsible for the various mental activities required
for day-to-day functioning. Mental illness can result when
there is disharmony or imbalance in the body’s energy
system, especially when the Shen is affected. A number of
etiological factors—such as constitutional makeup, fetal
trauma, improper diet, overwork, excessive sexual activity,
and narcotic drugs—can create such an imbalance.
The exact mechanism by which acupuncture induces phys-
iological changes, relieves pain, and alleviates illness is still
unclear. Research has shown that treatment with acupuncture
results in local and systemic effects, such as an increased
release of pituitary beta-endorphins and ACTH.7 The release
of endorphins may partly explain the analgesic effects of this
treatment, whereas increased ACTH secretion—which leads
to elevated serum cortisol levels—may account for its anti-
inflammatory effects. Acupuncture can also lead to acceler-
ated synthesis and release of serotonin and noradrenaline in
the central nervous system,8 with activation of descending
antinociceptive pathways and deactivation of multiple limbic
areas subserving pain association.9 Clinical studies of the
efficacy of acupuncture for psychiatric illness are often con-
vincing but still inconclusive in many areas. Thus, we present
a literature review (using Medline, 1966–2007) on the effec-
tiveness of acupuncture for 4 Axis I disorders: depression,
anxiety disorders, schizophrenia, and substance abuse.
Depression
Depression is the most common psychiatric illness in the
United States, with a prevalence as high as 18.9% in the
primary care setting.10 Many who suffer from depression
may remain undiagnosed or inadequately treated because of
a failure to recognize symptoms, underestimation of sever-
ity, limited access to health care, reluctance to see a mental
healthcare specialist, noncompliance with treatment, or lack
of health insurance.11 Conventional medical treatment is
problematic for several reasons. First, as many as 35% of
patients do not respond to conventional treatment, perhaps
more so among those with chronic illness.12 Second, although
compliance with next-generation selective serotonin reuptake
inhibitor medications has improved, the dropout rate is as high
as 15%.13 Last, a number of clinical trials have failed to
demonstrate a significant difference between active treatment
and placebo groups,14 undermining the public’s confidence
in these drugs. Women may be hesitant to initiate treatment
during childbearing years, and elderly patients may have
comorbid medical conditions that warrant specialist expertise
or contraindicate the use of these drugs.
56
TCM teaches that depressive symptoms result from dis-
harmony between the physical Qi and the spiritual Shen
energies of the body. According to the Five-Element school
of TCM, 3 distinct forms of depression exist, each with its
own predominant emotional imbalance: Earth type (worry),
Water type (fear), and Wood type (anger). Each of these
forms of depression correspond to an imbalance in one of
3 internal organ systems: the spleen/stomach (Earth), the
kidneys (Water), and the liver (Wood). In most instances,
the depressed patient may suffer from more than 1. The
imbalance can be caused by internal organ deficiencies (eg,
innate deficiency of kidney Qi), excesses (eg, stagnation of
liver Qi caused by repressed anger), or both. As with many
other ailments, TCM recommends an integrated approach
to treatment, using herbal remedies and acupuncture in
addition to nutrition and other lifestyle changes.
Depression is among the top 10 diagnoses for which
patients turn to CAM treatment, often as a result of dissatis-
faction with conventional treatments, the feeling of personal
autonomy and empowerment offered by CAM therapies, and
compatibility with personal values and beliefs.15 Acupunc-
ture may alleviate symptoms of depression through central
effects, such as the release of noradrenaline and serotonin,8 or
as a result of patient expectations. Although many research-
ers who have examined the efficacy of acupuncture treatment
for depression were limited by study size and methodology,
enough evidence exists to support a role for this treatment
modality. In their double-blind, placebo-controlled, multi-
center study of first 29 and then 241 depressed inpatients,
Luo et al16 found electroacupuncture to be as effective as
amitriptyline for depressive symptoms. Patients in this study
who were treated with acupuncture had better outcomes with
respect to somatization and cognitive process disturbances
than did those treated with medication, an effect that Yang
et al17 also observed. Acupuncture is also a promising treat-
ment for depression during pregnancy.18 Table 1 summarizes
clinical study findings regarding the efficacy of acupuncture
for depression.
Anxiety Disorders
Anxiety disorders are the second most prevalent psychiat-
ric condition in the United States, with a lifetime prevalence
of 5%.24 Anxiety is also a common complaint in any medical
environment, especially in prehospital and inhospital set-
tings. Because preoperative anxiety has a negative effect on
postoperative outcomes,25 physicians use sedative medica-
tions and preparation programs to treat preoperative anxiety,
which is a practice that incurs increased operational costs for
the healthcare system. According to TCM, anxiety results
from an innate deficiency of the heart and kidney energies,
Behavioral Medicine

TABLE 1. Clinical Trials of Acupuncture Treatment for Depression
Source Year conducted
Luo et al16 1998
Yang et al17 1994
Manber et al18 2004
Allen et al19 1998
Gallagher et al20 2001
Han et al21 2004
Macpherson et al22 2004
Roschke et al23 2000
Note. RCT = randomized controlled trial.
excess of liver Qi, and a lack of communication between the
heart and the kidneys, among other imbalances.
Acupuncture may alleviate anxiety through a number
of mechanisms. Acupuncture results in a “stillness,” with
prominent alpha rhythm in electroencephalography read-
ings, deep general relaxation, and a high degree of unre-
sponsiveness to ordinarily painful stimuli.26 Acupuncture
also can modulate the neuropeptide Y system in the baso-
lateral amygdale of rats,27 increase nocturnal endogenic
melatonin secretion in humans,28 and increase the release
of previously mentioned endogenous endorphins. Investiga-
tors studying acupuncture as a treatment for anxiety have
observed beneficial responses. In a prospective, random-
ized, placebo-controlled trial of 30 patients scheduled to
undergo colonoscopy, Fanti et al29 found that treatment
with acupuncture decreased patients’ demand for sedative
drugs, reducing both discomfort and anxiety during the
procedure. In another randomized, blinded, controlled trial
of 91 ambulatory surgery patients, Wang et al30 found that
patients treated with auricular acupuncture at relaxation
Vol 34, Summer 2008
SAMUELS ET AL
n Study format and conclusions
270 RCT, double-blinded; acupuncture as
effective as amitryptiline, more
effective for anxiety somatization and
cognitive process disturbance and with
less side effects.
41 Acupuncture as effective as amitryptiline,
more effective in reducing anxiety
somatization.
61 Acupuncture significantly more effective
than massage therapy for pregnant
women with depression, more so when
depression-specific points used.
38 RCT; acupuncture significantly more
effective than waiting list, more so
when depression-specific points used.
33 RCT, double-blind; relapse rates
comparable to medical treatments.
61 RCT; equivocal symptom reduction with
less side effects than maprotiline.
16 RCT; acupuncture showed significant
improvement vs no treatment.
71 Addition of acupuncture (either true or
sham) to mianserin treatment was
significantly more effective than
mianserin treatment alone.
points reported significantly lower levels of anxiety than did
controls. Table 2 summarizes results from clinical studies of
the efficacy of acupuncture on anxiety-related conditions.
Schizophrenia
Schizophrenia is a psychiatric illness characterized by
thought disturbances, bizarre behavior, and cognitive impair-
ment that may diminish a person’s social relations, school,
work, and self-care. Because of the distorted thought pro-
cess, treatment is difficult and conventional treatments are
of limited benefit. Antipsychotic medication has limited
efficacy and many potential side effects, with second-gener-
ation agents such as Clozapine more effective but requiring
frequent monitoring of the leukocyte count. Newer agents
such as Risperidone have a relatively safer profile and result
in lower recurrence rates.37
TCM categorizes schizophrenia as 2 types: depressive
psychosis and manic psychosis. The onset of the depres-
sive form is gradual and accompanied by reduced mental
clarity, followed by incoherent speech, mood swings,
57
ACUPUNCTURE FOR PSYCHIATRIC ILLNESS

TABLE 2. Clinical Trials of Acupuncture Treatment for Anxiety

Source Year conducted n Study format and conclusions

Spence et al28 2004 18 Uncontrolled; significant improvement in

polysomnographic measurements, as
well as reduced state and trait anxiety
scores.
Fanti et al29 2003 30 RCT; true acupuncture significantly more
effective than sham or no-acupuncture
treatment of precolonoscopy anxiety.
Wang et al30 2001 91 RCT; true AA treatment significantly
reduced anxiety vs sham treatment, but
not more than relaxation.
Kober et al31 2003 36 RCT; true AA significantly more effective
than sham for prehospitalization anxiety.
Liu et al32 1998 240 RCT; acupuncture as effective as behavioral
desensitization for anxiety neurosis;
combined treatment has higher cure rates.
Lo et al33 1979 8 Uncontrolled; 6 patients with anxiety
neurosis had good to moderate responses,
2 had no response.
Paraskeva et al34 2004 50 RCT; true acupuncture reduced Bispectral
Index and Verbal Score Scale (VSS) in
patients with pre-operative anxiety; sham
treatment reduced only VSS.
Shuaib et al35 1977 40 Uncontrolled; acupuncture reduced
symptoms of restlessness, tension, mental
or physical fatigue, anorexia, and
irritablility, with poor response for
obsessional symptoms.
Wang et al36 2001 55 Uncontrolled; true treatment significantly
reduced anxiety when compared to sham
treatment.

Note. RCT = randomized controlled trial; AA = auricular acupuncture.

anorexia, and insomnia. Depressive psychosis requires Substance Abuse

regulating Qi, alleviating mental depression, and calming
Shen. The onset of manic psychosis is sudden and accom-
panied by irritability, excessive motor activity, and abusive
and violent behavior. This form of schizophrenia must be
treated by cooling and calming methods that tranquilize
the mind and calm the Shen. Few clinical studies in the
field of acupuncture treatment address schizophrenia,
with only 1 comparative study38 and a few case reports39–
41
published. However, electroacupuncture may increase
the urinary secretion of 3-methoxy-4-hydroxypheylglycol
sulphate,42 a metabolite of noradrenaline that is inversely
related to the severity of illness in schizophrenics.43 The
clinical significance of this finding has yet to be correlated
with clinically significant findings.
Substance abuse is prevalent in Western society, with
as many as 15% of patients who present to a primary
care practice exhibiting an at-risk pattern of alcohol use
or an alcohol-related health problem, and 5% a history of
illicit drug use.44 Treatment of addiction is limited by poor
compliance and toxic effects of long-acting agents that are
substituted for the abused drug and then tapered gradually.
In TCM, drugs such as cannabis, cocaine, heroine, and LSD
deeply affect Shen, with prolonged use leading to confu-
sion, memory loss, and decreased concentration.45
Although many clinical studies of auricular acupunc-
ture treatment for substance abuse have been published,
the results are far from conclusive. In a randomized

58 Behavioral Medicine
 SAMUELS ET AL

controlled trial of 82 cocaine-dependent methadone-main-
tained patients, Avants et al46 found that those assigned to
acupuncture treatment were significantly more likely to
provide cocaine-negative urine samples than were controls.
Margolin et al47 repeated the study protocol (N = 620) but
found no difference between the groups. The latter authors
posited that the discrepancy in outcome may have resulted
from factors such as differences between counseling pro-
tocols. Also, a participation payment in the second study
may have fostered retention of more severely addicted and
unmotivated patients. Table 3 provides a substance-specific
list of clinical studies.
COMMENT
Psychiatric illness is both common and complex, with
conventional therapeutic options limited by partial efficacy,
toxicity, and poor patient compliance. Acupuncture is a
safe and effective treatment option that, along with other
CAM treatments, patients with psychiatric illness choose
far more often than do nonpsychiatric patients. When used
in conjunction with conventional therapies, CAM treatment
modalities such as acupuncture do not decrease adherence
to conventional medical treatment.62–65 Although patient
compliance is high for acupuncture treatment of chronic
pain,66 it remains to be shown that psychiatric patients
would be as compliant.
Many of the studies cited regarding the Axis 1 psychi-
atric diagnoses presented are either not yet convincing (as
with schizophrenia) or show conflicting results (as with
substance abuse). Better studies of disorders such as depres-
sion have been conducted, although it is still not possible to
recommend routine use of acupuncture for this disorder.67
The Cochrane Corporation, via its Cochrane Database
of Systematic Reviews, has investigated the efficacy of
acupuncture treatment for depression,68 schizophrenia,69
and cocaine dependence.70 Each review reached the same
conclusion: because of poor design and a limited number
of studies, there is no evidence that acupuncture is effective
for any of these conditions.
A recent Institute of Medicine committee was formed at
the request of the National Center for Complementary and
Integrative Medicine of the US National Institutes of Health
to define principles that will guide the research agenda for
CAM. The committee recommendation was that “the same
principles and standards of evidence of treatment effective-
ness apply to all treatments, whether currently labeled as
conventional medicine or CAM.”71(p149) At the same time,
however, the world of conventional medicine is expected

TABLE 3. Clinical Trials of Auricular Acupuncture for Substance Abuse

Source Year conducted n Study format and conclusions

Alcohol
Bullock et al48 1987 54 RCT; true vs sham; significant benefit
Bullock et al49 1989 80 RCT; true vs sham; significant benefit
Bullock et al50 2002 503 RCT; true vs sham; no significant benefit
Karst et al51 2002 34 Uncontrolled study; significant benefit
Sapir-Weise52 1999 72 RCT; true vs sham; no significant benefit
Trumpler et al53 2003 48 RCT; true vs sham; no significant benefit
Zalewska-Kaszubska et al54 2004 53 Uncontrolled; no significant benefit
Cocaine
Avants et al46 2000 82 RCT; true vs sham; significant benefit
Margolin et al47 2002 620 RCT; true vs sham; no significant benefit
Avants et al55 1995 40 RCT; true vs sham; significant for craving
Bullock et al56 1999 438 RCT; true vs sham; no significant benefit
Lipton et al57 1994 150 RCT; true vs placebo; no significant benefit
Margolin et al58 2002 48 RCT; true vs sham; no significant benefit
Otto et al59 1998 36 RCT; treatment vs none; no significant benefit
Schwartz et al60 1999 6907 Retrospective cohort; significant benefit
Heroin
Washburn et al61 1993 100 RCT; true vs sham; significant benefit

Note. RCT = randomized controlled trial.

Vol 34, Summer 2008 59

ACUPUNCTURE FOR PSYCHIATRIC ILLNESS
to take CAM seriously. For this to happen, future research-
ers must conduct large and controlled studies, unlike most
of the studies presented here, which are small and, at best,
exhibit limited statistical power. Such studies would allow
mental health professionals to consider acupuncture a com-
plementary treatment with the potential to augment current
therapy and increase the frequency of positive outcomes
without increasing the risk for potentially harmful effects.
NOTE
For comments and further information, address cor-
respondence to Dr Noah Samuels, The Center for Inte-
grative Complementary Medicine, Shaare Zedek Medi-
cal Center, P.O.B. 3235, Jerusalem 91031, Israel (e-mail:
refplus@netvision.net.il).
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Behavioral Medicine
 Call For
Papers

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Behavioral Medicine welcomes all submissions of pertinent manuscripts.

Behavioral Medicine is an interdisciplinary journal of research and practice that deals with
psychosocial influences on health and behavior. It publishes original research studies, both
experimental and clinical; evaluation studies; review articles; case reports; and book reviews.

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