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Acupuncture against depression

Professional assignment of Project (PAP)


:
Contractors: Xiaolu Hou &Juncal Román
Client:Contra-expertise en Inspanningsonderzoek naar Arbeids belastbaarheid
Coach:Cia Kesselaar

Hogeschool van Amsterdam Eurpean School of Physiotherapy


29-Jan-07 2007 Amsterdam The Netherlands

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Acupuncture against depression

Professional assignment of Project (PAP)


:
Contractors: Xiaolu Hou &Juncal Román
Client:Contra-expertise en Inspanningsonderzoek naar Arbeids belastbaarheid
Coach:Cia Kesselaar

Hogeschool van Amsterdam Eurpean School of Physiotherapy


29-Jan-07 2007 Amsterdam The Netherlands

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CONTENTS

FOREWARD ...................................................................................................................................5
INTRODUCTION............................................................................................................................5
RESEARCH QUESTION..............................................................................................................6
ABSTRACT ....................................................................................................................................6
BACKGROUND..............................................................................................................................6
Hypothesis ...................................................................................................................................7
CLINICAL RELEVANCE............................................................................................................7
PT relevance................................................................................................................................8
Massage therapy .....................................................................................................................8
Exercise therapy .....................................................................................................................8
Quality of life ..............................................................................................................................9
MATERIAL Y METHODS...........................................................................................................9
RESULTS......................................................................................................................................10
DISCUSSION ...............................................................................................................................13
What can we improve? ............................................................................................................15
CONCLUSION.............................................................................................................................15
AKNOWLEGMENTS .................................................................................................................15
APPENDIX A ...............................................................................................................................16
APPENDIX B……………………………………………………………………..……………..16
REFERENCES.............................................................................................................................20

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FOREWARD

Throughout the study of physiotherapy the western medical methods have been applied over and
over again, with little regard for Chinease medicine. This can be seen as an error of judgment, with
an idea that these methods are of little value. We have chosen to research one area of traditional
medicine to show its value is sientficaly recorded.

INTRODUCTION

First of all, the topic was chosen between both of us, because there was an interesting opportunity
to search about depression and acupuncture due to the increase of the number of the patients with
that dissease worldwide and because of the significant number of them who arrive to the
physiotherapy clinics to be treated.
Its known, that depression is a common disease. Lot of times, there is not proper diagnosis proceed
and even the diagnosis is well done, the established treatment is not correct. The acupuncture is
widely thought to be an effective treatment..

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RESEARCH QUESTION

What are the effects of acupuncture treatment for


depression?
ABSTRACT

Background: Depression is recognized as a major public health problem, which has a substantial
impact on individuals and to society. Acupuncture has become a popular complementary and
alternative treatment approach for depression treatment.
Research question: What are the effects of acupuncture treatment for depression? _
Physiotherapy relevance: Nowadays the increase of depressive patients in the physiotherapy
clinics and the more competitive requirements makes the physiotherapy to look for new therapies
that may have good results combined with traditional therapy
.
Method: This document is a systematic review; it is descriptive, observational, longitudinal and
retrospective.

Results: Acupuncture has positive effects in depressive patients but still there is not enough
evidence. Only in one study there was full remission of the symptoms.

Conclusion: Acupuncture is beneficial in reducing the symptoms of depression either as an


adjunctive treatment or instead of medication.

Keywords: Depression, depressive disorders, acupuncture, physiotherapy, major depression,


acupuncture, TCM.

BACKGROUND
society. Depressive disorders are common in
Clinical depression is defined a syndrome the general population. The rate of depression
with symptoms of low mood, loss of pleasure among women is two to three times that of
and interest, sleep disturbances, weight and men The World Health Organization has
appetite changes, fatigue, feelings of described depression as an “unseen burdenii.”
worthlessness or guilt, poor concentration The Global Burden of Disease study reported
and (when severe) suicidal thoughts and that when measured by Disability Adjusted
gestures, that persist for at least two Life Years (DALY), unipolar major
weeks.11i. depression ranked fourth in 1990, and would
Depression is recognized as a major public rise to second by 2020, in terms of the overall
health problem, which has a substantial burden of all diseases.
impact on individuals and to Recent studies on depression in primary care
have demonstrated that it is necessary to

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improve the identification of this clinical Chinese philosophical ideas of Yin and Yang
condition. Approximately 50% to 60% of the and the Five Elements which form the basis
cases are not detected, and even the patients of Chinese medical theory. These theories
who receive correct diagnosis often are not form the basis for explaining disease and
given an appropriate and specific treatmentiii. physiological function. A westernized
Depression in a primary care clinic: the medical application of acupuncture involves
prevalence and impact of an unrecognized the use of acupuncture administered in
disorder. It has been estimated that the relation to mainstream, and using trigger
average time interval between symptom onset, points, segmental points and commonly used
identification and treatment of the disorder is formula points. Medical acupuncture may
4 to 6 yearsiv. involve the application of acupuncture based
If a proper treatment was delivered, the on the principles of
prevention of morbid-mortality caused by Neurophysiology and anatomy, and the
depression could be as high as 70% v . exclusion of TCM principles and
Consequently, although the patients of philosophyvii.
primary care units present mild depressive
symptoms if compared to cases of major Hypothesis
depression, the under diagnosis of such
symptoms has an impact on the individuals' Our hypothesis in fact is acupuncture has
life, not only regarding the presence of positive effect for depression treatment.
symptoms, but also causing impairment of The nul hypothesis is that there is no
quality of life and social functioning, and significant impact of acupuncture upon
increasing the use of health resourcesvi. ;. depression.

We have undertaken an analysis of studies


conducted to assess the efficacy of CLINICAL RELEVANCE
acupuncture in treating depression. In
primary care depression is most frequently Mayor depression symptoms
treated with antidepressants (Goldman 1999).
In addition, there are a range of psychological For a diagnosis of major depression
interventions, including cognitive behavior (DSM-IV), 5 or more of the following
therapies, interpersonal therapy, symptoms should have been present for at
psychotherapy and counseling. least 2 weeks. Either item 1 or 2 must always
be presents.
Acupuncture has a long history of use in
China and Japan. Traditional Chinese
medicine theory describes a state of health 1. Low or sad mood (specifically if worse
maintained by a balance of energy in the body. in the morning)
Acupuncture involves the insertion of fine 2. Loss of interest or pleasure in usual
needles into different parts of the body to activities (anhedonia)
correct the imbalance of energy in the body. 3. Fatigue or loss of energy
There are a range of styles of acupuncture 4. Appetite disturbance or weight change
from traditional / classical acupuncture, 5. Sleep disturbance or weight change
auricular acupuncture, trigger point 6. Difficulties in concentrating
acupuncture, and single point acupuncture. 7. Feelings of guilt or self blame
Traditional Chinese Medicine (TCM) and 8. Feelings of worthlessness
Classical Acupuncture is based on the 9. Suicidal ideas or thoughts

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10. Objective evidence of agitation or may have good results combined with
retardation traditional therapy. Acupuncture and its
effectiveness of it will be discussed
Major Depression Coding
Classical treatment
Major depression can be code according to
severity, psychotic features, and somatic For all the classical therapy for depression
(melancholic) features. treatment we found two therapies:
The severity of depression can be classified
as mild, moderate, or severe. 1. Massage therapy:

• In mild depression, the individual has Massage therapy involves the


some symptoms of depression, and manipulation of the soft tissue by
extra effort is required to do the things physical therapists for therapeutic
that need to be done. Mild depression purposes.
is usually associated with only Massage therapy has ancient origins. We
impairment in occupational or social can find two different mechanisms for
functioning. effect in depression

• Moderate depression involves • Massage shifts


occupational or social impairment electroencephalogram activation
which is midway between the form a right frontal pattern 8
impairment associated with mild and associated with the sad effect) to a
severe depression. The individual has left frontal or symmetrical pattern
symptoms of depression that often (associated with happy affect)
keep him or her form doing things • Massage increase vagal activity
that need to be done. and stimulates facial expression
and vocalizations which
Severe depression involves marked contribute to less depressed affect
impairment in these areas and may • The problem we find in
include psychotic symptoms. The physiotherapy, form the limited
individual has nearly all the symptoms of evidence available, massage
depression and the depression almost therapy appears to have short
always keeps the individual form doing terms benefits have not been
his or her regular day-to-day activities. evaluated viii
Somatic features are nearly always
present vii.
2. Exercise therapy
PT relevance Exercise can improve endurance or improve
strength, flexibility or coordination.
Physiotherapist meets many depressed
patients. The physiotherapy is able to help the Psychologically based explanations suggest
patients with their depression. Nowadays the that exercise might interrupt dysfunctional
increase of depressive patients and the more thoughts, serve to distract negative thoughts,
competitive requirements makes the or, if the exercise programs are supervised or
physiotherapy to look for new therapies that conducted in groups, increase social

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interaction. Exercise may increase levels of depressive symptoms looked for health
monoamine neurotransmitters that mediate assistance at primary care clinics more
stress and depressive reactions. Strenuous Often, had longer hospital stays and missed
exercise may release endorphins, which have more workdays than the less depressed
morphine like qualities. Fitness levels are patients x.
lower in depressed individuals. Therefore, it
has been argued that increased aerobic fitness
MATERIAL Y METHODS
may directly lift mood ix.
This document is a systematic review; it is
Quality of life descriptive, observational, longitudinal and
retrospective.
There are many components that affect the The key words used for finding the articles
well-being or quality of life. were: Depression, depressive disorders,
There are several studies that demonstrated acupuncture, physiotherapy, major
that the severity of the depressive disorder depression, acupuncture, TCM.
affects all dimensions of quality of life, even
when controlled with other variable, such as The database used for the database used for
age. the research Pubmed, Cocrane, Medline,
Sometimes this can cause the same or more Thelancet, Amed, PiCarta, MEDLINE,
severe impairment than other chronic PEDRO, Cochrane Central Database of
diseases. International studies have Systematic Reviews, and CINAHL,.
demonstrated that functional impairment and
use of health resources are directly All abstract that covered the required subject
proportional to the severity of the depressive were collected, most of the articles were not
symptoms, it is important to foreground that complete, and reading the abstracts and
mild depressive disorders that do not meet the finding out which were suitable for our thesis
criteria for major depressive disorder can also they were obtained from UVA.
cause significant impairment in quality of
life. The article were then excluded or included
including to the preliminary criteria:
In Brazil there was made an study for the • Articles in English
assessment of quality of life regarding the Many of the articles are in Chinese, but
severity of depressive symptoms in patients both experimenters may read all articles
of primary care clinic showed that the and give a second review.
patients those with more sever symptoms • Full articles
considers their health as being worse and less Many abstracts are available, but they do
satisfied with its health status than those not contain all the information necessary
patients with milder symptoms, even thought for our systematic review
many patients did not present major
• No systematic reviews
depressive disorders.
• Because they already included
Al so we can find an inverse correlation
references and they do not experiment
between depressive symtomatology and other
by themselves.
parameters of quality of life, such as
impairment of physical and psychological • Less than ten years old
functioning. Regarding the use of health Because because then dater is no longer
resources, the patients who presented more valid.

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interval (100% inter-tester relaiblity). This
A criteria list was constructed, using meant no third read through was necessary.
guidelines from PEDRO and module 2.3 EBP There were only 2 articles where different
(Hva Esp course.) scores were given by the two testers and a
Each article was reviewed by both of the group third, blinded assessor gave a score that
members and given a score out of 40 correlated with the first assesors score. This,
according to the criteria list (appendix A) again, was repeated after the two week period
41 relevant abstracts were found, 7 past the with the same score given.
inclusion criteria for full investigation. A
break down is shown in figure 1. The maximal score available was 40,
minimum 0. The mean score was 29 (73%)
Articles that did not match in the inclusion with a range of 22 to 35.
criteria, we used then as supplement The standard deviation is 4.5 (24.5 – 33.5)
information for contribution of our paper (see table 1)

Articles that past the inclusion criteria will be 5 of the 7 articles gained a score above 70%
reviewed by two assessors who will follow (see figure2), which qualifies them as high
the criteria list. With a minimum interval of quality articles and their p values have been
two weeks they will then be reassessed by the noted in table 2.
same assessors. A second reading is taken to As can be seen by this table only 1 of the
test inter-tester reliability and a two week gap 7 articles found there to be no significance in
is given so scores are no given from memory. the use of acupuncture against depression.
If a deviation was found between the two Of the 5 articles considered of high validity, 4
inter-tester scores the paper will be showed a high p value (p<0.05)
reassessed by both parties.
If a discrepancy is found between the scores
of the two reviewers, a third party will be Figure 1
asked to review the article twice, again with a
two week interval. The criteria list will be
explained to the external reviewer but the 41 abstracts
scores obtained by the two reviewers will not
be disclosed.

The end score will be taken as the mode from


the 6 reviews if discrepancy existed. A mean 9 articles excluded as
full article not available
end score will then be calculated, a score
above 70% (28) will be taken as a result of 15 articles excluded as over 10 years old
high quality articles.
The p values shown in al articles obtaining
this result will be discussed as answers to the 6 articles excluded as not in English

research question. A p value of 0.05 or above


will be used as significant. 4 articles excluded as
systematic reviews

RESULTS
7 articles included

On review the testers found that they


recorded the same result after the two week

10
Criteria list results

40

35

30

25
Score

20

15

10

0
5 1 6 4 2 3 7
Article number

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Number Author Name of the article Score Score Score End
Xiaolu Juncal External score
Reviewer

1 Dr.Chen, et,al.2005 A Study on the Criteria for the 24 24 24


Commonly Seen TCM
Syndromes of Depression

2 Dr.Xu Hong,et,al., Effect of Acupuncture on the 31 32 31 31


2005 Hypothalamus-pituitary-adrenal
Axis in patients with depression

3 Rachel Acupuncture: a promising 32 32 32


Manbera,*,et,al., treatment for depression
2004 during pregnancy

4 Joo Im Quah-Smith, Laser acupuncture for mild to 30 30 30


Wai Mun Tang, moderate
Janice Russell.2005 depression in a primary care
setting
– a randomised controlled trial

5 HUGH Acupuncture for Depression: 22 22 22


MACPHERSON, First Steps Toward a
B.Sc., Clinical Evaluation
Ph.D.,1,2,et,al.,2004

6 J. Ro¨schke*, The benefit from whole body 29 29 29


Et,al.,1998 acupuncture in major
depression

7 John J.B. THE EFFICACY OF 35 36 35 35


Allen,1,et,al.,1998 ACUPUNCTURE IN THE
TREATMENT OF MAJOR
DEPRESSION IN WOMEN

Table 1

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Article no Compairing P value Main conclusion

High value studies

2 Acupuncture to <0.05 – none specific The therapeutic effect of


baseline acupuncture on depression is
parallel to the function of the
hypothalamus-pituitary-adrenal
axis. Acupuncture can produce the
same effects as Fluxetine but
without side-effect such as nausea,
vomiting and tachycardia.
3 MSSG to acupuncture 0.031 Acupuncture can produce better
clinical outcome. Massage treatment
as comparison i s not significant.
4 No treatment to laser 0.001 Laser acupuncture as a new
acupuncture. approach treatment is significant
then no treatment .but there is
side-effect.
6 Placebo and no 0.048 Additionally applied acupuncture
treatment to did improve the course of depression
acupuncture core than pharmacological
treatment with mianserin did by
itself. This study could not detect
any differences between placebo and
verum acupuncture. There is no
specific effect of needing defined
acupuncture points in the treatment
of major depression
7 Specific to non specific <0.05 –non specific Included insufficient sample sizes,
acupuncture description about drop-out,
Various approaches have been
employed.
Lower value studies

1 TCM tests to 0.001 Stagnation of the liver-qi is the basic


traditional depression syndrome of the disease. The other
tests syndromes still have their own
specific main symptoms. But clinical
tests still need to broaden.
5 Acupuncture to 0.04 More about evaluating acupuncture
baseline foe patients with depression but no
comparisons for clinical trail.
The pathogenesis of depression is mainly
failure of the liver in promoting free flow
DISCUSSION of qi, dysfunction of the spleen in
transformation and transportation,
Description of Traditional Chinese Medicine
malnutrition of the heart and disturbance
TCM holds that endogenous emotional of yin and yang,qi and blood of the
impairment is the causative factor of zang-fu organs. At the initial stage, the
depression. disease is mainly due to stagnation of qi,
complicated with blood stasis turning

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into fire, belonging to the excess with symptoms indicating deficiency of
syndrome. In prolonged cases, excess the heart-blood such as palpitation,
may turn into deficiency, which, forgetfulness, less and dreamy sleep but
also with symptoms indicating deficiency
according to the varying affected zang-fu of the spleen such as poor appetite and
organs and consumption of qi and blood sallow complexion; and the syndrome of
and yin and yang, may cause different yin-deficiency of both the liver and
pathologic changes of consumption of the kidney is not only complicated with
liver, spleen, heart and kidney. feverish sensation in the palms and soles,
night sweating and thready-rapid pulse
It has been shown by epidemiological characteristic of yin-deficiency in nature,
investigation that the showing rate of but also with dry eyes and soreness and
mental depression has reached over weakness in the waist and knee joints
99.6% in the four syndromes of characteristic of the symptom of the liver
stagnation of the liver-qi, stagnation of and kidney in location. The authors think
the liver-qi and deficiency of the spleen, that the criteria set in the research foe the
stagnation of the liver-qi and phlegm and commonly-seen TCM syndromes of
deficiency of both the heart and spleen depression can not only reflect the
and 96.4% in the syndrome of characteristics of the disease. But also the
yin-deficiency of both the liver and essence of the syndromeviii.
kidney, suggesting that mental
depression is the characteristic symptom The results of the studies concluded that
of depression and is thus taken as the the acupuncture has positive effects
essential symptom in the various TCM treating patients with depression but there
syndromes of depression. According to are no concrete data that can prove it.
the results of factorial analysis, mental Only in one of the studies is seen that
depression, pessimism and depressed there was a full remission of all the
expression dominated by Public Factor 1 symptoms of the patients (J.J.B.Allen,
are taken as the basic symptoms for “liver 1998).
depression” in the syndromes of In other article is written how they
stagnation of the liver-qi stagnation of the compare the effectiveness of acupuncture
liver-qi and deficiency of the spleen and versus massage and in the results the
stagnation of the liver-qi and phlegm. In conclude the acupuncture to be more
addition to the basic symptoms .the effective, but the problem they have is
syndrome of stagnation of the liver-qi that the time for the massage session and
and deficiency of the spleen is also acupuncture session is in both 20min,
complicated with symptoms indicating being a normal session of massage longer
spleen figure and allow complexion; the so this results does not conclude the
syndrome stagnation of the liver-qi and effectiveness of acupuncture over
phlegm is complicated sensation in the massage.
throat and sticky tongue coating,
indicating obstructing of turbid phlegm; Comparing these results to those found in
the syndrome of deficiency of both the the systematic review we have shown
heat and spleen is not only complicated that we have the same level of
significance in the outcome.

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What can we improve? Therefore, future research can address
whether the treatment gains are
maintained or whether less-frequent
1. more articles, more could give us more continuation or maintenance treatment
significant results are required after the initial set of
treatments.
2. more money, because lot of full articles
is not for free from the database. If we
have more money, then we can pay for CONCLUSION
them and get them for our research.
Based upon our results of the 7 articles
3. more time, because due to the school we propose that acupuncture might be
schedule .we only have no more than 15 beneficial in reducing the symptoms of
weeks ( a Christmas holiday between) for depression either as an adjunctive
organization and transportation for treatment or instead of medication. We
finding more articles. also suggest that acupuncture is more
favorable than social interaction and
If additional research corroborates that contact. The treatment dose is not yet
acupuncture is an effective treatment for established .for side-effect from
depression, further research should medication .acupuncture seems to be a
address several issues. First, good way for reducing depression..
acupuncture’s effectiveness remains to be However most of the studies have
determined foe severe of chronic methodological limitations. To establish
depressions (e.g., chronic major the effects of acupuncture as an
depression, dysthymia) as well as for intervention in reducing depression more
persons with comorbid disorders ( e.g. research and evidence is needed.
anxiety disorders , substance
dependence ). Second, the long term
prognosis of patients who respond to
acupuncture treatment is unknown.

AKNOWLEDGMENTS

Special thanks to Cia Kesslar(our coach)


and also as our client for her valuable
input. Thanks to Miranda Asher and
Tonje Thingvoll our classmates who
were helping a lot.

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APPENDIX A: Literature Grading List

Article Title:

Graded by:

MANDATORY INCLUSION CRITERIA

Articles must not be systematic reviews


YES/NO
Reason: The results can not be compaired

All the articles should be written in the last 5


years YES/NO

Reason: To ensure the material is current and


valid

Only articles in the English language can be used

Reason: To enable consistent analysis between YES/NO


group members and to ensure the highest
possible quality in evidence based research

Only full articles can be included

Reason: To ensure all sections can be scored YES/NO

GRADING CRITERIA

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Research question: Use of the PICO method –
Max score 8 points

Patient or Problem: The problem should be


adequately defined. 2
Intervention: Should be clearly stated and the
reasons for using that intervention. 2 /8
Comparison: State specifically to which other
treatment the intervention is compared and
motivate the choice. 2
Outcome: What the researchers hope to
accomplish should be stated clearly. 2
Abstract: Maximum score 2 points

Is purpose clearly stated? 1


Are most pertinent results and conclusions /2
stated? 1
7. Introduction: Maximum score 2 points

Is the background information adequate? 1 /2


Is the hypothesis stated? 1
8. Materials and Methods: Maximum score 14
points

Eligibilty criteria specified. 1


Subjects in the research described. 1
Subjects randomly allocated to groups. 2
Groups similar at baseline. 2
Blinding of subjects. 1
Blinding of assessors. 1 /14

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Blinding of administrators. 1
Sampling method properly described. 1
Procedure clearly defined. 1
Have materials selected been clearly
described? 1
Is evidence of tool reliability and validity
described? 1
Is exact procedure given in a format that
would allow a reader to reproduce the
experiment exactly: 1
9. Results: Maximum score 8 points

Are the results clear and concise? 2


Are any graphs provided clear and useful? 1
Is statistical data present and significant for
key outcomes? 2 /8
Measures of variability given for key
outcomes? 2
Are dropouts explained? 1
Conclusion and Discussion: Maximum
score 8 points
Answer to research hypothesis? 2
Are limitations in the research described? 1
Comparison to previous similar studies? 1
Suggestions for further research, reasons? /5
1
References: Maximum score 1 point

Are the references cited in a correct, /1


consistent fashion? 1
TOTAL SCORE /40

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Appendix B. Articles used for the thesis.

1. Manaber .R, Schnyer.R,Allen.J.J.B, Rush.A.J, Blasey.C.m. Acupuncture: a promising treatment


for depression during pregnancy. Journal of Affective Disorders 83 (2004) 89–95

2. Macpherson. H, Thorpe L,. Thomas K., and Geddes D., Acupuncture for depression: First steps
toward a clinical evaluation. The journal of alternative and complementarz medicine, 2004;
Volume 10, Number 6, pp. 1083–1091

3. Quah-Smith.J.I, Tang.W.m, Russell.J. Laser acupuncture for mild to moderate


Depression in a primary care setting – a randomised controlled trial. Acupunture in Medicine. 2005;
23(3):103-111.

4. Wolf.Ch, Muller.M.J, Wagner.P, Mann.K, Bech.S. The benefit from whole body acupuncture in
major depression. Journal of Affective Disorders. 2000: 57; 73–81

5. Dr.Chen.Dr.Zeqi.Dr.Hu Suiyu.Dr.Zhang Hainan,Dr.Zhang Honggeng,Dr.Zheng Lin,Dr,Li


Xiaozhao* A Study on the Criteria for the Commonly Seen TCM Syndromes of Depression. The
euroupean journal,August 2005.

6. Dr.Xu Hong,Dr.Sun Zhongren,Dr.Li Liping,Dr.Tong Shuiai,Dr. Wangsheng,Dr.Hua


Jinshuang*Effect of Acupuncture on the Hypothalamus-pituitary-adrenal Axis in patients with
depression. The European journal, August 2005

7.John,J.B.Allen, Rosa N.Schnyer,and Sabrina K.Hitt. THE EFFICACY OF ACUPUNCTURE IN


THE TREATMENT OF MAJOR DEPRESSION IN WOMEN.VOL.9.NO.5.SEPTEMBER.1998.

19
REFERENCES

i
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-Tr. 4th ed.
Washington DC: American Psychiatric Publishing Inc; 2005

ii
Murray CJ, Lopez AD. The global burden of disease. Geneva: World Health Organisation and Harvard University
Press, 1996.
iii
McQuaid, J.R., Stein, M.B., Laffaye, C., McCahill, M.E., 1999.
iv
Schwenk, T.L., Evans, D.L., Laden, S.K., Lewis, L., 2004. Treatment outcome and physician–patient
communication in primary care patients with chronic, recurrent depression. Am. J. Psychiatry 161 (10), 1892–1901.).
v
Docherty, J.P., 1997. Barriers to the diagnosis of depression in primary care. J. Clin. Psychiatry 58 (Suppl 1), 5–10..
vi
Cuijpers, P., de Graaf, R., Van Dorsselaer, S., 2004. Minor depression: risk prof iles, functional disability, health care
use and risk of developing major depression. J. Affect. Disorder. 79 (1–3), 71–79.
vi
Goldney, R.D., Fisher, L.J., Dal Grande, E., Taylor, A.W., 2004. Subsyndromal depression: prevalence, use of health
services and quality of life in an Australian population. Soc. Psychiatry Psychiatr. Epidemiol. 39 (4), 293–298)
vii
Macpherson. H, Thorpe L,. Thomas K., and Geddes D., Acupuncture for depression: First steps toward a clinical
evaluation. The journal of alternative and complementarz medicine,2004; Volume 10, Number 6, pp. 1083–1091
viii Field T. Massage therapy effects. Am psychol 1998; 53: 1270-1281
ix(Dr.chen,Dr.Zeqi,Dr. Hu suiyu, Dr.Zhang Hainan, Dr. Zhang Honggeng, Dr. Zheng Lin, Dr. Li Xiaozhao A Study
on the Criteria for the Commonly Seen TCM Syndromes of Depression, The European journal ,august 2005)
x Barros da Silva.A.F, Pio de Almeida. M. Subsyndromal depression: An impact on quality of life?. Journal of
Affective Disrders. 2006

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