Stimulated by Liu et al 2023.[1]
GAD – generalised anxiety disorder
key to acronyms
HAMA – Hamilton anxiety scale
GAD-7 – general anxiety disorder scale (7-item)
PSQI – Pittsburgh sleep quality index
ACTH – adrenocorticotropic hormone
EA – electroacupuncture
CTS – carpal tunnel syndrome
This paper reports the first sham controlled trial of acupuncture in perimenopausal GAD. It comes from a single centre in Gaungzhou, which as mentioned previously on this blog is part of the largest urban agglomeration on the planet. It is on the Pearl river and connects with its 4 neighbouring cites of Foshan, Dongguan, Zhongshan, and Shenzhen. The latter of the 4 being directly above Hong Kong.
The group appear to have developed their own sham acupuncture device, which allows both perpendicular and oblique insertion of needles. In a previous trial on acupuncture for anxiety in Parkinson’s disease, they claim that the acupuncturists were also masked by using this device.[2] The device has two versions that look identical but that differ on the base – one version allows a needle to penetrate and the other does not. In this previous trial, ‘operation assistants’ applied the devices to patients and the ‘acupuncture operators’ then tapped in the needles in. Well, I am not completely convinced by this description, but let’s move on and return to perimenopausal GAD.
There were 56 women in each arm of this sham controlled trial and the treatment involved 12 sessions over 4 weeks with follow up at 1 and 3 months. Each session was 30 minutes and involved 10 needles (either penetrating through the device or not). There were 6 on the head and 1 in each limb (HT7 and SP6). The points on the head were 4 surrounding GV20, called Sishenzhen (not to be confused with Sishencong) plus GV24 and Yintang.
The difference between Sishenzhen and Sishencong is a mere half a cun, the former being further away from GV20 than the latter by that distance, so 1.5 cun to the left, right, front, and back of GV20 rather than just 1 cun. This means that the points behind and in front of GV20 are actually the acupuncture points GV19 and GV21.
The outcomes used were HAMA (primary outcome), GAD-7, and PSQI, plus serum cortisol and ACTH was measured before and after the course of treatment.
The mean baseline HAMA was just over 21, which correlates to moderate severity. Both groups improved over the 4 weeks of treatment, but the effect was greater in the penetrating acupuncture group and this effect seemed stable for the 3 months of follow-up, whereas the effect in the non-penetrating sham group relapsed somewhat by 3 months.
GAD-7 scores also improved more in the penetrating acupuncture group, but there was no difference in the PSQI or cortisol. There was a difference in serum ACTH after the course of treatment that just reached statistical significance.
In the previous trial from the same group on GAD in Parkinson’s disease, the treatment course was twice as long and there was no difference between real and sham at the end of the treatment phase, but a difference emerged after a further 8 weeks when the group receiving the real acupuncture improved further and those receiving sham regressed to their baseline level of severity on the HAMA. There was a similar trend in the figures of the current trial, but the differences were more apparent during treatment as well. We have seen this before in subjective outcomes despite differences in objective outcomes in a trial of EA in CTS – see Rewiring the brain with acupuncture.
Perhaps the effect of a very convincing sham generates powerful expectation and conditioning effects during the treatment but fades much more rapidly than the real physiological changes of penetrating acupuncture.
References
1 Liu X, Li M, Xie X, et al. Efficacy of manual acupuncture vs. placebo acupuncture for generalized anxiety disorder (GAD) in perimenopausal women: a randomized, single-blinded controlled trial. Front Psychiatry. 2023;14:1240489.
2 Zhou J-H, Zhang D-L, Ning B-L, et al. The Role of Acupuncture in Hormonal Shock-Induced Cognitive-Related Symptoms in Perimenopausal Depression: A Randomized Clinical Controlled Trial. Front Psychiatry. 2021;12:772523.
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