Traditional Acupuncture and Oriental Medicine Intervention on Long-Term PTSD and Depression

Caitlin A. Connor

Both depression and post-traumatic stress disorder (PTSD) occur at a high rate in urban populations in the US and can be very debilitating. There are high numbers of veterans returning from Middle Eastern conflicts, often with PTSD. Research has shown that veterans commit suicide at approximately a rate of 22 per day (O’Neal, 2015). Long-term depression often presents in combination with PTSD and has a recovery rate that is equally poor with a high rate of recidivism (Murray & Fortinberry, 2015). This suggests that for both groups, quality of life is suffering. Unfortunately, this is an area where Western conventional medical treatment may not have a long-term benefit (Steinert et al., 2015).

Chronic illness is a significant issue in healthcare today and the costs associated with chronic illness and chronic care are significant. Conventional treatment also has limited success in symptom improvement in many chronic conditions. Acupuncture has a history of treating chronic illness successfully and cost-effectively (Cummings, 2009; Furlan et al., 2010; Hinman et al., 2014). Supporting research within the acupuncture community is a key component in promoting improved quality of life for humanity and in continuing to develop methods to successfully address healthcare issues.  

Post-Traumatic Stress Disorder (PTSD) has a long history with many different names but was first officially defined as PTSD in 1980 in the DSM- III (American Psychiatric Association, 1980). It has layers with both physiological and psychological effects. There are over 500 research references found in the National Library of Science database, showing that there has been a lot of research done on PTSD in the last ten years, but so far that research has failed to find a cure. Instead, it has focused primarily on reducing reactions in individuals to the point where they cannot react to situations in daily life that trigger symptoms. This does reduce visible symptoms but does not clear the underlying residuals from their traumas.

There is equally no cure for those experiencing severe chronic depression (National Institute of Mental Health [NIMH], 2022a). Antidepressants work for 35% to 45% of the depressed population, though more recent figures suggest rates as low as 30%. Antidepressants, particularly SSRIs, work only as well (or less) than placebos (Murray & Fortinberry, 2015). NIMH states that 16 weeks of therapy has a 47% relapse rate within 12 months and a 46% remission rate with medication (NIMH, 2022a). Acupuncture has a long history of successfully treating chronic health issues (Cummings, 2009; Furlan et al., 2010; Hinman et al., 2014; Linde et al., 2009; Manheimer et al., 2010; Vickers et al., 2012; Vickers & Linde, 2014), as well as influencing mental/emotional problems, despite cultural avoidance of any mention of mental health issues. (Hopton et al., 2014). As such it is a reasonable step to explore Traditional Chinese Medicine’s (TCM’s) impact on new and changing mental health issues.

Many programs across the country, such as the “Wounded Warrior Project”, are making efforts to address and resolve the underlying issues (Westat, 2015). Most interventions provided today still focus on Cognitive Behavioral Therapy (CBT), which is a form of talk therapy; Exposure Therapy (ET) (McLean et al., 2022); or Eye Movement Desensitization and Reprocessing (EMDR) (Mayo Clinic, 2018).  NIMH (2022b) has stated that “To be diagnosed with PTSD, a person must have all of the following for at least 1 month: at least one re-experiencing symptom, at least three avoidance symptoms, at least two hyper-arousal symptoms, symptoms that make it hard to go about daily life, go to school or work, be with friends, and take care of important tasks. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.” (NIMH, 2015).

While Western treatment has reasonable success with acute depression, it has been notably unsuccessful with the treatment of chronic depression. Major depression is currently defined (NIMH, 2015) as:

…severe symptoms that interfere with your ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes. People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of symptoms vary depending on the individual and his or her particular illness. Signs and symptoms include: Persistent sad, anxious, or “empty” feelings, feelings of hopelessness or pessimism, feelings of guilt, worthlessness, or helplessness, irritability, restlessness, loss of interest in activities or hobbies once pleasurable, including sex, fatigue and decreased energy, difficulty concentrating, remembering details, and making decisions, insomnia, early-morning wakefulness, or excessive sleeping, overeating, or appetite loss, thoughts of suicide, suicide attempts, aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

Acupuncture has a rich and different perspective from that of standard Western medicine and has a 3000-year history from which to pull. It is important to remember when researching traditional medicine forms, that there is often no direct correlation between diagnosis. There is no corresponding single TCM pattern that matches the Western diagnosis of PTSD and severe depression. However, there are trends in diagnosis that apply to this area of Western diagnosis such as Liver Yang Rising, as both are defined by a constellation of symptoms. 

One of the most commonly diagnosed Traditional Chinese Medicine (TCM) patterns for PTSD is Liver Qi Stagnation. This covers a number of acute symptoms, such as emotional disturbance and insomnia, as well as some of the underlying patterns. Based on Connor (2022), this TCM diagnosis appears to be more of a secondary pattern and not the underlying cause. Heart Shen disturbance, caused by heat or a constitutional deficiency, is also commonly referenced in the literature (Kim et al., 2013), and includes symptoms such as anxiety, stress, and difficulty breathing, all of which are also common with PTSD. 

One of the most commonly diagnosed Traditional Chinese Medicine (TCM) patterns for PTSD is Liver Qi Stagnation. This covers a number of acute symptoms, such as emotional disturbance and insomnia, as well as some of the underlying patterns.

Current information now maps the meridian system as overlapping parts of the lymphatic system (Ahn et al., 2005; Feinstein, 2010). It also appears to overlap elements of the nervous system. The concept of the release of “Qi,” or static bio-electric overcharge on an area of the lymphatic system is consistent with the evidence that the body has a variety of electro-dermal potentials across its surface (Becker & Selden, 1985; Flick, 2004) and that acupuncture points are strategic conductors of electromagnetic signals (Ahn et al., 2005, Feinstein, 2010, Lee at al., 2009).  

The National Institute of Health Consensus Statement on Acupuncture (1998) provides a succinct summary of the gradually growing acceptance of acupuncture in the U.S.:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

Qi Gong and Meditation are also considered part of TCM. Qi Gong is defined as “an ancient Chinese healing art involving meditation, controlled breathing, and movement exercises”, (Merriam-Webster, n.d.b, para. 1), and Meditation is defined as “the act or process of spending time in quiet thought” (Merriam-Webster, n.d.a, para. 1).

Current research regarding acupuncture and PTSD is primarily focused on refugee populations and the military community. However, the quality of reports is fairly diverse, as is shown in the comparison between various careful reviews of the literature.  For instance, Lee et al. (2013) present a meta-analysis of 52 out of 1480 studies focused on trauma spectrum responses to acupuncture treatments that met strict research criteria (Lee et al., 2013).  Lee concludes that “acupuncture appears to be effective for treating headaches, and although more research is needed, seems to be a promising treatment option for anxiety, sleep disturbances, depression and chronic pain” (Lee et al., 2013, p.1). In contrast, Kim et al. (2013), were much more narrowly focused and detailed in their analysis. They did a systematic review of randomized controlled clinical trials or prospective clinical trials and of 136 only six met their criteria. They concluded that “acupuncture plus moxibustion vs. SSRIs favored acupuncture plus moxibustion” (Kim et al., 2013, p. 1). 

Moxibustion is a technique commonly used in TCM. It involves the burning of mugwort leaves either near or on the body to warm or energize areas that have been identified as cold or deficient. Further, recent studies further support the efficacy of acupuncture for the treatment of PTSD. Engel et al. (2014) demonstrated positive results, though with a small sample size of 55 subjects, with a 12-week intervention. Hollifield et al. (2007), showed a significant effect of acupuncture (p < 0.01) in the PTSD group and also showed improvement in anxiety, depression, and sleep issues. Sniezek et al. (2013) found significant differences between acupuncture for depression and at least one control group in all six trials they reviewed.  In addition, data showed continuing areas of secondary improvement. Overall “there is high-level evidence to support the use of acupuncture for treating major depressive disorder in pregnancy” (Sniezek et al., 2013, p. 1). Wang et al. (2014), showed p < 0.05 on PTSD and depression for acupuncture, with SSRI compared to SSRIs only. Spackman et al. (2014) showed that acupuncture for depression was a cost-effective method of improving the overall quality of life, as contrasted to both counseling and usual care. Arvidsdotter et al. (2013) showed an improvement over conventional treatment for subjects with both anxiety and depression, though integrative therapy appeared to be equally as strong. 

Acupressure is also a recognized component of TCM, and a modality that has researched effects. McPherson et al. (2013), show that self-care strategies can contribute to the treatment of PTSD. A survey by Feinstein (2010) showed that a variety of Energy Psychology tapping techniques on acupuncture points were successful interventions for the treatment of PTSD. Folkes (2002) showed similar results with Thought Field Therapy, a specific Energy Psychology method. Energy Psychology techniques which involve tapping on acupuncture points as a self-management technique for participants to use between regular acupuncture sessions may increase the effectiveness of treatments. 

Energy Psychology techniques which involve tapping on acupuncture points as a self management technique for participants to use between regular acupuncture sessions may increase the effectiveness of treatments.

Connor, 2022 found that consistent improvements were shown when the presenting complaint was directly addressed and that significant shifts in all symptoms were seen in all three cases starting in week five of treatments (Connor, 2022). In all the cases, where there were comorbid issues, addressing the direct needs of the patient rather than the Western diagnosis, as would be done in Western medicine, showed a more direct benefit to the individual (Connor, 2022). Distinct improvement was made in significant areas of discomfort because they were directly addressed and not suppressed (Connor, 2022). Key findings were a reduction in PCL-C scores on an average of 18 points over the eight weeks, and that all subjects moved from the severe depression rating to the mild-moderate (Connor, 2022). Norming on the PCL-C suggests changes between 5-8 points over a substantially longer period primarily with the use of cognitive-behavioral treatment applications (Weathers et al., 1993). Most notably, an extended analysis of results within the individual answers to each of the questions by case on the PCL-C showed improvement in the area of chief complaint in each case study (Connor, 2022). In severe long-term depression, remission is possible but is not generally sustained. In cases where the severe depression has continued in excess of five years, remission is unusual and the Western standard of care is medication maintenance expected throughout the rest of the patient’s life. It is important to note the frequent change of needling patterns and herbs in the treatment process in each of these cases in the study, as practitioners with limited training and standardized diagnosis skills should not be encouraged to treat individuals in these categories (Connor, 2022). Significant damage to the patients can occur in this very vulnerable population.

Traditional Chinese Medicine (TCM) treatment has shown success in improving PTSD and long-term severe depression. Comparisons between overall treatments would be needed, as well as the flexibility to build individual treatment plans focusing on the disparate areas of the individual chief complaint. Acupuncture shows promise as being able to treat a complicated mixture of psychological and physiological issues.

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