A compilation of studies on acupuncture, depression and western treatment was analyzed for the effectiveness of acupuncture for the treatment of depression. The fundamentals of depression, acupuncture and antidepressants are discussed. Acupuncture was found to be at least equally effective if not even better than antidepressants. It increased intracephalic blood flow and stimulated monoamine production, and decreased clinical depressive symptoms, as well as giving a sense of well being to the patient, and had with few side effects when compared with antidepressant drugs and electroconvulsive therapy. Electroacupuncture is superior to conventional acupuncture in treating depression and is more effective than electroconvulsive therapy when given as a series of treatments. Finally, clinical depression is found not to be solely a neurotransmitter imbalance but it is also an imbalance in the meridians. Both Western and Eastern practitioners in the healing arts must see that clinical depression is a multifaceted condition that must be addressed through many types of healing paradigms to have effective treatment.
Acupuncture and Depression
Depression is one of society’s main mental health problems. At any one time, four percent of men and six percent of women have this condition while the lifetime risk in general is about 17 percent.   Depression is a disease which transcends age groups. Young infants may even develop its symptoms although the peak usually occurs around late adolescence and early adulthood.
Acupuncture has been a Chinese healing art for over 5000 years. It involves the use of a filiform needle being inserted into a part of the anatomy, which in turn corresponds to an acupuncture point. These acupuncture points interconnect with each other in organized patterns called meridians. There are 14 major meridians in the body. Each meridian corresponds to an organ or function . The theory is that vital life energy, qi, is blocked when a health condition, such as depression, is at certain acupuncture points throughout the body. When an acupuncture needle is inserted into an acupoint, it is postulated that the qi, which is blocked or stagnated at the point, is allowed to flow freely throughout the meridian .
The purpose of this paper is to determine if acupuncture can play an important part of the treatment of depression and how it can act as an adjunct to conventional (Western) medicine.
Western Definition of Depression
In medicine, there are two theories on depression; The biochemical theory and the neurotransmitter theory. The biochemical theory of depression is due to hormonal imbalances. There is a dysfunction in the hypothalamic-pituitary-thyroid axis , mainly in the hypothalamus, which controls mood, appetite and sexual interest  which may display abnormal hormone levels during depressive episodes . Low serum thyroxine is a major hormone associated with depression, with or without subclinical hypothyroidism, and the thyroid hormone cascade of lowered levels of thyrotropin releasing hormone that affects the thyroid stimulating hormone  .
Ascending to the neurotransmitter theory, there are imbalances in the catecholamine levels, namely norepinephrine and serotonin. Serotonin is synthesized from 5-hydroxytryptophan in neurons in the hypothalamus and brainstem.  Proof of this theory is the current effective use of antidepressant medication for affected patients. 
The criteria for a major depressive episode (also known as clinical depression) is extracted from 
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e. g. feels sad or empty) or observation made by others (e. g. appears tearful). Note: In children and adolescents, can be irritable mood.
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) Significant weight loss when not dieting or weight gain (e. g., a change of more than 5% body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional nearly every day (not merely self reproach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. These symptoms do not meet criteria for a Mixed Episode
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of s substance (e. g. a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism.)
E. The symptoms are not better accounted for by Bereavement, i. e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Conventional treatments for clinical depression are (1) medication, (2) psychotherapy, (3) medication and psychotherapy combination, and (4) electroconvulsive therapy .
The most widespread treatment of depression in western medicine is the application of anti-depressants. They are drugs which change the biochemistry of the nervous system. Drug classes include the old monoamine oxidase inhibitors (MAOIs), which interfere with the monoamine oxidase enzyme from degrading norepinephrine and serotonin; tricyclics, which block the reuptake of norepinephrine and serotonin; and the newer generation selective serotonin reuptake inhibitors (SSRIs), which block uptake of serotonin only .
Cautions for use of these medications are countless side effects such as the length of time for it to reach therapeutic levels, ease of overdosing on tricyclics, headaches, upset stomach and sexual dysfunction. Patient non-compliance due to the latter side effect has an impact on the regression of the depressive condition .
Eastern Definition of Depression
In acupuncture, depression is defined as a "pulmonal orb depletion" with the major yin cardinal of the hand i.e. Lung Meridian . Symptoms of this depletion include thorax congestion, cough, oppressed breathing, asthma, the sensation of heat ascension in the thorax, pain under the clavicle, heat in the palms, and stiffness in the lower arm . Emotions associated are grief and dejection.
Also, suppressed emotions stagnate cardiac qi, causes mental illness. This affects the Heart Meridian Symptoms include insomnia, restivenss, nightmares, forgetfulness, inconsistency of speech and actions. Treatment of this would include HT 7, P6, P7.
Treatment of affective disorders, including depression, using acupuncture includes the following acupoint tables as described in , and including LU 1, the great forgiveness/antidepressant point  .
General affective condition:
GV20 increase mental alertness and balances mind
LI4 clears mind in the upper body ad improves mental function, relieves worry and anxiety
HT7 calms the heart and mind, decreases worry and anxiety and sleep disturbances
P6 Calms mind and relieves anxiety
CV 6 Increases the ability to cope
CV12 Balances digestive organs and restores emotional stability
CV17 Calms the heart and mind
ST 36 Invigorates digestive organs and increases vitality and emotional stability
Memory and concentration:
BL10 Decreases tension and increases circulation in the neck, increases memory and concentration
BL23 increases kidney energy and is powerful for memory and concentration
KI6 Clears mind and improves concentration
GV26 Clears mind and relieves depression
BL10 Relieves depression
CV12 Balances digestive organs and restores emotional stability
LV3 Improves liver function
GB12 Decreases restlessness, disturbed sleep and excessive dreaming due to liver imbalance
SP6 balances spleen, liver, and kidney meridians and nourishes blood, sleep easier
KI3 Improves heart and kidney function
P8 Calms mind and decreases mental agitation
LU11 Calms agitation and restores mental ability
BL18 Improves liver function
LV3 Improves liver function
In auriculotherapy there are two antidepressant points found which are to stimulate cheerfulness and joy. These points are on LO8 and CW3 in the ear. 
Classical acupuncturists may rely on a 5 Element rule for treating "depressed" patients. This is described as follows by Schneider-Guild 
In TCM alone, there are many approaches to the same problem. The scope of this article is on the five elements and their significance in diagnosing and treating depression. Each element encompasses a symptomological picture that varies from the others. Becoming aware that a patient is depressed does not suffice. It is important to understand and address the individual and unique manifestations of that person's depression. The five elements provide a clear and interesting framework in which many cases of depressive illness can fit, be diagnosed and treated. For the sake of clarity, this article will present each element and its unique manifestations, without addressing the interactions of the elements. Although elemental interdependence is fundamental to the five-element theory, it is the goal of this article to highlight the differences among the elements in order to present a clear theoretical model. It should be understood that cases of purely Wood-element depression, for example. would be rare. Usually there is a combination of elements in the same person, which will hopefully become more decipherable through deeper understanding of each element.
The Wood Element
When considering the Wood element, one thinks of the obvious characteristics such as Spring, Wind, Eyes, Tears, Shouting, Anger, Sour, etc. However, there are also more subtle features pertaining to this element that are less obvious, but can be of great value when determining a person's elemental predominance. For example, some of the traits of a Wood case of depression could be that the patient has a great deal of difficulty relaxing or being at ease, that they want to control everything and fall into depression when defeated, and they have a stormy type of personality that is prone to many moods. The Wood personality can be arrogant, confident, aggressive, confrontational, driven and eager. They can be very demanding of themselves and others. and can easily be disappointed at which point they may fall into the clutches of a darkness known as depression. Usually this type of depression has a great well of repressed anger, disappointment, and frustration brewing underneath the surface. The primary issue is control in the Wood cases. As far as their appearance, a Wood type may present with a reddish facial skin tone, reddish eyes, and disgruntled look. Wood types are usually rather tall and slender.
The Fire Element
The Fire type, on the other hand, has quite different features than those of Wood. A Fire element depression most often has to do with relationships and "heartbreak." Most frequently, Fire types feel let-down or disillusioned by love. Their depressions are usually of a cyclical nature in that they get over one heartbreak, and then move on to the next. Their depressions can be quite severe, and they can often become suicidal due to their impulsive, and "living on the edge" character type. Fire predominance includes symptoms of anxiety, chest pains, nightmares of a vivid nature, and a lack of laughter and the ability to feel joyous. Depressive episodes readily deplete heart qi, and can cause the usual Fire related symptoms of palpitations, shortness of breath, mental confusion (due to the heart's relationship to the Shen or cognitive functioning of the individual), and listlessness. Since all emotions have an influence on the heart, the Fire element can transmit imbalances that stem from other organ or emotional disturbances. Yet. in those cases there would be a mixed symptomological picture. As far as appearance is concerned, the Fire types tend to have a reddish face with a rather pointy chin. Their hair tends to be curly, and when in balance they tend to move quickly and to frequently be in a rush. When depressed, however, they tend to feel unmotivated and unable to appreciate the beauty of life that they usually thrive on. Paradoxically, their strong point is also their weak point in that Fire types lean towards vigorous and healthy blood and blood vessels when well, but can easily become depleted in this area when out of balance. Since the heart rules the blood. Fire predominance can lend itself to a host of blood related and mental problems when the individual succumbs to stress and relational pressures.
The Earth Element
The Earth element would encompass its typically characteristic digestive imbalances. However, in depressive episodes, Earth types tend towards significant changes in their eating habits. Some will have no appetite whatsoever, whereas others become ravenous and try to eat in order to fill the dark emptiness inside. It appears to be a way of seeking warmth and comfort. When depressed, Earth elementers become unmovable, perhaps because they have a tendency towards dampness. At any rate, they virtually sink into their depressions and become heavy and unmotivated. The Earth element's energies contribute greatly to the human affect of centeredness, being grounded, peace, calm and compassion. In adversity, the serenity of this element becomes distorted into listlessness, obsessive worry, overconcern and their sense of self strongly diminishes as they lose their usual propensity to being grounded.
The Earth element's physical characteristics are unique, and usually quite detectable. They tend to be stockier, more portly, and generally move more slowly than most of the other elements. They often have round faces, and appear rather jovial when in balance. An interesting note is that their body shapes can alter significantly when under the duress of depressive illness. They may fluctuate in weight, depending on their individual tendency to either halt or greatly increase their food intake. A major clue in recognizing Earth element cases is their oral natures. They often need to have something in their mouth - chewing gum, candies, foods. Perhaps this is the reason for their propensity towards being damp and somewhat overweight.
The Metal Element
The Metal element encompasses a great deal of issues regarding giving and taking to and from the environment. Frequently, this element winds up depressed when there is loss or grief. Often these emotions can be repressed and manifest in unusual respiratory difficulties, asthmas, and frequent upper respiratory infections. Commonly, when depressed, Metal types sigh, cry and sob, and lack a sense of boundary between the "self' and others. They are prone to the sufferance of the world, which is termed "weltschmerz'' This is a Freudian term that depicts the person who takes the pains and suffering of the world onto their own shoulders. Therefore, this type of a case may also involve a sense of grieving that seems overwhelming and all-encompassing. The Metal element types are environmentally sensitive, but are also more easily influenced in a therapeutic setting with regards to their emotional status. They often appear with soft weak voices, and pale complexions. They are generally of thin stature and when depressed, appear meager and weak. In many cases, these patients will have rather clear regrets over the past and feel that there is a significant desire to wish things could only have gone differently. These people often feel plagued by circumstance, and therefore grieve over past issues and losses that they hang on to.
In strong contrast to the above mentioned elements is the Water element. This is the most clinically significant and potentially dangerous type of elemental depression. This is the element that is most greatly influenced by the pre-natal Jing - hence, genetics. In these cases, the patient is depressed and does not have any insight into why or any reasons that may have caused the descent into a depressive illness. These patients are most susceptible to severe psychological imbalances, such as schizophrenia, psychoses, and severe major depressive episodes. In many cases. the patient will become despondent and unable to do even the simplest of chores for themselves. Their depression seems to reach down into the very core of the person's being - their spirit and soul. These patients become incommunicable, and sink rather deeply into their illness. These are the most difficult of all of the elements to treat successfully. These patients appear desperate, paranoid, and out of touch. They fear life and death, and don't have any sense of what their fear means. Usually these people feel that they are beyond help, and no longer seek assistance in their grave dilemma over their life. They also reluctantly fear leaving their homes, and seem to lose their sense of purpose in life. They may appear in a clinic, usually accompanied, and be ungroomed, easily distracted and very scattered. They may have nervous tremors, and seem fearful or totally apathetic. These cases may be misdiagnosed, because it is easy to interpret the patient's signs as arrogance or poor hygiene. Yet, it is important to recognize the desperation of the person's plight because these patients are the ones most prone to suicidal tendencies. Since they feel so lost and don't grasp what is plaguing them on such a pervasive and personal level, they often resort to the ultimate escape from their misery - suicide.
In each of the elements discussed, there are specific clues and hints as to which element is predominant in the given case. It is helpful to ask questions that may evoke the necessary information in order to reach a diagnosis. One must use tact, empathy and a direct approach that is not overly involved, while still maintaining a concerned and caring disposition. The use of the five elements is only a tool in diagnosing and dealing with a case of depression. The elements afford practitioners an added sense of comprehension and clarity in a patient's case. However, it is important to focus on the most comprehensive and effective means of treatment. As alternative health care practitioners, it is also crucial to recognize the importance of dealing with the patient on a psychologically therapeutic level. In most cases of depression, there are unseen, underlying triggers that we as acupuncturists are not trained to deal with. Hence, it requires a delicate balance that always keeps the patients' best interests foremost in mind.
In conclusion, depression must be dealt with on every level of the person's being. The theoretical model of the five elements can be useful in diagnosing and treating a patient suffering from depressive illness. As stated previously, it is vital to assess the severity of a depressive's condition, and tend to their individual needs. In any case, the five-element approach can be seen as one perspective in dealing with these conditions.
Current Research and Discussion
In his book, Dr. Ming Wong reports that acupuncture "is equivalent to the effect of tranquilizers in cases of depression, worry, insomnia, and nervous disorders, and its action is swift and long lasting."  Evidence to support this statement comes from Ernst’s study, where levels of endorphins through acupuncture needling increased, and stated that acupuncture provides promising evidence for the treatment of depression , whereas electroacupuncture provides a greater efficacy in alleviating the depressive state over conventional acupuncture. Also, Tsai’s research, where acupuncture stimulation released cerebral serotonin, provoked an anti-depressant as well as an analgesic effect, improved sleep pattern, therapeutic relaxation and the ease of withdrawal of medications. The patient also had mental clarity and alertness due to the lowering of the levels of antidepressants in the blood due to a decreasing dependence of the drug, thus reducing their toxic side-effects . Locations for these points included DU20 and Yintang (EX1), GB20, P6, HT7, ST36, SP6, KI3. Self-assessment scales were used for patient ratings on their health and the percentage of improvement was remarkable: 78.8% improvement of mental disorders and 77.1 % improvement of physical disorders from slight to remarkable improvement .
LINK BETWEEN WESTERN SYMPTOMATOLOGY
AND EASTERN EXPLANATION
There is a correlative relationship between asthma and mood disorders, namely clinical depression, in inner city asthma patients . This demonstrates a correlation of the Lung Meridian as a treatment for depression. This is the Pulmonal Orb dysfunction previously described.
ACUPUNCTURE AND THE BRAIN
A study discussing stimulation of acupoints ST 36 and GB20 reported that increased intracephalic blood flow helped transport more nutrients to the brain , namely the amino acid tryptophan and its metabolites in the synthesis of serotonin . Other research linked electroacupuncture in facilitating the stimulation of a c-fos protein, which is a third messenger protein that ultimately stimulated serotonergic neurons . Now that acupuncture is known to be able to manipulate neurotransmitters Riederer’s study identified acupoints for their ability to treat depression (He gu = LI 4, zhou san li = ST36, tai chong = LI3) and were studied for nervous conditions . There were increases in the metabolites of neurotransmitters in blood and urine samples, which suggested that there were more neurotransmitters being produced in the brain after acupuncture treatment . Another study demonstrated acupuncture points Baihui (GV 20) and Yintang (EX 1), both also known for treating depression , when electrically stimulated, produced significantly increased levels of cerebral serotonin in rats , and in clinical trials was found to alleviate some symptoms of mental illnesses in patients, and the authors suggested that there is an increased turnover rate in serotonin metabolism after electroacupuncture treatment . This suggests that there is more serotonin production in the brain after acupuncture treatment. Research involving one of the known acupoints for depression, pai-hui (GV20), acupuncture helped the memory storage process, where memory loss is a criterion for the western diagnosis of major depressive disorder .
Animal studies involving manipulating the monoamine levels in the periaqueductal gray of the rat brain demonstrated that electroacupuncture increased the amount of serotonin levels in that part of anatomy . Other research in support of electroacupuncture for depression included an animal trial in which serotonin and norepinephrine synthesis was accelerated . Clinical data for this experiment concluded that electroacupuncture is effective in treating depressive patients with effectiveness equal to and higher than the tricyclic amitriptyline .
ACUPUNCTURE COMPARED TO ANTIDEPRESSANTS
Other clinical research compared electroacupuncture with antidepressants . The tricyclic amitriptyline was the drug of choice for this comparison study. Results hailed electroacupuncture equal to amitriptyline for depressive disorders but also had a better therapeutic effect for anxiety somatization and cognitive process disturbance over the drug . In addition, electroacupuncture had fewer side effects than amitriptyline and was heralded as an effective therapeutic method for depressive disorders, and was the treatment of choice for patients who were not able to withstand the side effects of the antidepressant .
WHERE WESTERN MEDICINE HAS FAILED THEM
One case study  found a 46-year-old mother with a clinical diagnosis of depression as a Western diagnosis demonstrated a typical pattern of illness described by traditional Chinese medicine as a "wind illness". Western medicine was not effective ("useless" as described in the article) in the treatment of the patient but acupuncture was beneficial. This demonstrates the difference between Eastern and Western practitioners and how they view a certain set of symptoms.
Whole body acupuncture was attempted in a study to "tonify" psychiatric patients, meaning to restore physiological homeostasis through standard acupuncture, for schizophrenic patients was attempted. Over 60 % of the patients received feelings of well being but not lasting more than three days . This is promising news as schizophrenia is suggested to be a condition that is due to an excess of brain monoamines, namely dopamine, that medication was thought to be the only way to treat them.
A Russian experiment made progress with some antidepressant-resistant patients who were bipolar which suggests that this sub-type of depression may not be a purely biochemical imbalance in the brain .
In a comparison study of non-painful acupuncture and electro convulsive therapy the electroacupuncture was not as effective as electroconvulsive therapy in single treatments but was superior in decreasing depressive symptomatology when a series of electroacupuncture treatments was given. Electroacupuncture was preferred over electroconvulsive therapy due to the latter’s side effects of temporary disabling memory defects .
Given the numerous research cited, acupuncture is at least equally effective if not even better than antidepressants. It increased intracephalic blood flow and stimulated monoamine production, and decreased symptoms as defined in the DSM-IV-TR, as well as giving a sense of well being to the patient. This is all done with few side effects when compared with antidepressant drugs and electroconvulsive therapy. Electroacupuncture is superior to conventional acupuncture in treating depression and is more effective than electroconvulsive therapy when given as a series of treatments. Finally, clinical depression is found not to be solely a neurotransmitter imbalance but it is also an imbalance in the meridians. Both Western and Eastern practitioners in the healing arts must see that clinical depression is a multifaceted condition that must be addressed through many types of healing paradigms to have effective treatment.
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