CC BY-NC-ND
0Clinical Observations
Clinical Research of Acupuncture on Malignant Tumor Patients for Improving Depression and Sleep Quality
FENG Yu ^ \ WANG Xin-yu 2, LI Shao-dan \ ZHANG Yin \ WANG Hai-ming \
LI Min ^^ \ CAO Ke \ YE Yu-fei \ and ZHANG Zhao 1
Objective: To study the effect of acupuncture on depression and insomnia of malignant tumor patients. Methods: Eighty cases of cancer related depression and sleep disorders were randomly divided into 2 groups: treatmentl group (acupuncture «=40) and control group (Fluoxetione n=40). All patients were assessed by Self-rating Depression Scale (SDS), Hemilton Depression Rating Scale (HAMD) and Pittsburgh Sleep Quality Index (PSQI) after treatment for 30 days.
Results: Before treatment the SDS and HAMD scores of the trial group were 64.12±5.34 and 20.92±2.38, those of the control group were 64.24±4.98 and 20.72±2.74, after treatment the SDS and HAMD scores of the trial group were 43.64±5.28 and 9.88±1.27 respectively, significantly lower than those of the control group (50.76±5.42 and 13.72±2.05 respectively, both P<0.05). Before treatment the PSQI score of the trial group and the control group were 14.48±1.71 and13.92±2.59, after treatment the PSQI score of the trial group was 7.92±1.22 after treatment, significantly lower than those of the control group (11.44+1.89, P<0.01).
Conclusion: Acupuncture can effectively reduce malignant-related depression, improve sleep quality, and help to
improve the quality of life of cancer patients.
Keywords: tumor; depression; sleep disorder; SDS; HAMD; PSQI
The existing researches indicate that most patients suffering from malignant tumor have the problem of depression with the incidence rate of 10%-25%. And their daily life conditions such as sleep quality and appetite are closely related to the depressed mood.3 In treating depression and sleep disorder, acupuncture has unique effect. The authors observed the therapeutic effects for depression and sleep quality of patients suffering from malignant tumor with pattern of phlegm-stasis binding. The results are as follows.
METHODS
General Data
Totally 80 patients suffering from malignant tumor were selected from both the outpatient and inpatient ward of Traditional Chinese Medicine (TCM) Department or Acupuncture Department of Chinese PLA General Hospital from October 2008 to October 2010. They were divided into treatment and control groups by random digits table with 40 patients in each group. The study was approved by the Ethical Committee of General Hospital of PLA, and all the patients signed the informed consent forms before treatment. Between the two groups, there was no statistical difference in gender, age and tumor type (P>0.05), thus they had comparability in the trial (Table 1, 2, 3).
Diagnostic Criteria
1. Diagnostic criteria of Western medicine: Depression occurs after the malignant tumor, and the depression meets the related standard of Chinese Classification and Diagnostic Criteria of Mental Disorders, 3rd ed, (CCMD-3).4
2. Diagnostic criteria of phlegm-stasis binding: the disease is caused by phlegm-stasis binding with the following symptoms: stuffy pain in chest,5,6 abdominal lumps and fullness or fixed stabbing pain, somber face and blue-green lips, sticky feeling in the mouth and lack of taste sensation, poor appetite and digestion, distention in the stomach duct, severe palpitations, yellow greasy coating, purple dusky tongue or with purple plague, or purple and swollen sublingual vein, slippery pulse or rough pulse.
Inclusion Standard
1. Meet the diagnostic criteria above-mentioned.
2. SDS (Self-rating Depression Scale) score >50, Hemilton Depression Rating Scale (HAMD) score >7, PSQI score >8.
3. Age between 18 and 75.
4. With no intellectual or mental disorders, being able to self-judge the sleep condition and other common conditions, being able to accomplish the scale independently.
5. Expected survival time being more than 3 months.
6. Signing informed consent.
Exclusion Standard
1. With functional disorders of the heart, liver, kidney and spinal cord.
2. Being incapable of understanding or accomplishing
1. Department of TCM, General Hospital of PLA, Beijing 100853, China; 2.Department of Acupuncture, General Hospital of PLA, Beijing 100853, China
Correspondence to: Prof. WANG Xin-yu, E-mail: wxy821@sina. com
the test due to dementia or low education level.
3. Taking antidepressant drugs at the present time.
4. Karnofsky score <30.
Trial Suspension Standard
1. During the observation period, appearing significant progress of the tumor and needing chemoradiotherapy or surgery.
2. The patient refuses to continue to participate in the trial.
3. With lower adherence to treatment, lost in follow-up.
Table 1. Gender comparison of patients in the two groups
Group Cases Male Female
Treatment group 40 26 14
Control group 40 27 13
Notes: %2 =0.0656, P>0.05.
Table 2. Age comparison of patients in the two groups
Group Cases Age (year)
Treatment group 40 63.80±5.47
Control group 40 63.60±4.26
Notes: i=0.1441, P>0.05
Table 3. Types of primary tumor in the two groups
Type Treatment Group Control Group
(Cases) (Cases)
Pulmonary cancer 14 16
Gastric cancer 8 8
Breast cancer 3 4
Colorectal cancer 9 5
Lymphoma 3 1
Cervical carcinoma 1 1
Ovarian cancer 2 2
Notes: %2 =0.1586, P>0.05
Methods of Treatment
Patients in the control group received Fluoxetine Hydrochloride Capsule (trade name: Prozac, produced by Patheon in France) 20 mg per day. In Treatment group, the patients were treated with acupuncture on the acupoints of Fenglong (ST 40), Yinlingquan (SP 9), Xuehai (SP 10), Sanyinjiao (SP 6), Yintang (EX-HN3), Baihui (DU 20), Sishencong (EX-HN1), Neiguan (PC 6) and Shenmen (TF 4). When needling, use the method of neutral supplementation and drainage. The patients were treated one time per day for 20-30 min, and the acupuncturist did needling manipulation at the interval of 5-10 min. One course of treatment was 30 days.
Assessment Tools and Evaluation Standards
1. Assessed depression conditions of patients in both groups before and after the treatment through SDS.7 2. Used HAMD of 17 points. Scores above 7 meant a possibility of depression; scores between 17 and 23 showed slight or moderate depression; and score above 24 was severe depression. Used HAMD reduced rate to
assess the therapeutic effectiveness.8 HAMD reduced rate (%) = (score before treatment—score after treatment) /score before treatment x 100%, cure rate (reduced rate > 75%), effective rate (reduced rate 50%-75%), improved rate (reduced rate 25%-49%), invalid rate (reduced rate <25%). 3. Used PSQI to assess sleep quality.9 Score between 8 and 12 showed slight insomnia; between 13 and 17, moderate insomnia; and between 18 and 21, severe insomnia. Selected the patients with PSQI >8 and compared their scores before and after the treatment.
Statistical Methods
Use the software of SPSS 11.5 and applied t test, Chi-square test and analysis of variance. P<0.05 was regarded as statistically difference, and P<0.01 was regarded as statistically significant difference.
RESULTS
SDS score results: before treatment, SDS scores of the treatment group and the control group were 64.12±5.34 and 64.24±4.98 respectively. There was no significant difference (P>0.05). However, after treatment, SDS scores of the treatment group and the control group were 43.64±5.28 and 50.76±5.42 respectively; which showed significant difference (P<0.05). The results indicated that acupuncture and Fluoxetine Hydrochloride capsule were both effective in relieving depression mood of patients suffering from malignant tumor; and the effectiveness of acupuncture was obviously higher.
Table 4. SDS scores before and after treatment of malignant tumor patients in the two groups (X + s)
Group Cases Before Treatment After Treatment
Treatment group 40 64.12±5.34 43.64±5.28*#
Control group 40 64.24±4.98 50.76±5.42**
Notes: *compared with score before treatment P<0.05, #compared with the control group P<0.05; "compared with score before treatment P<0.05.
HAMD score results: before treatment, HAMD scores of the treatment group and the control group were 20.92±2.38 and 20.72±2.74 respectively. There was no significant difference (P>0.05). However, after treatment, HAMD scores of the treatment group and the control group were 9.88±1.27 and 13.72±2.05 respectively; which significant difference (P<0.05). The results indicated that acupuncture and Fluoxetine Hydrochloride capsule were both effective in relieving depression mood of patients suffering from malignant tumor; and the effectiveness of acupuncture was obviously higher.
Table 5. HAMD scores before and after treatment of malignant tumor patients in the two groups ( X + s)
Group_Cases Before Treatment After Treatment
Treatment group 40 20.92±2.38 9.88±1.27A#
Control group 40 20.72±2.74 13.72±2.05A Notes: ^compared with score before treatment P<0.05, "compared with the control group P<0.05; Acompared with score before treatment, P<0.05.
Therapeutic evaluation results of depressed mood: After the treatment for 30 days, assessed therapeutic effectiveness according to the standards. In the treatment group, there were 3 patients being cured, 25 patients getting significant effectiveness, 7 patients being improved, and 5 patients getting no effect. The effective rate was 87.5% (35/40). In the control group, there was no patient being cured, 2 patients getting significant effectiveness, 25 patients being improved, and 13 patients getting no effectiveness. The effective rate was 67.5% (27/40). The treatment effectiveness in two groups was significantly different (x2=4.5878, P<0.05).
PSQI score results: PSQI scores of the treatment group before and after treatment were 14.48±1.71 and 7.92±1.22 respectively, the difference was significant (P<0.001) according to statistical analysis. For the control group, PSQI scores before and after treatment were 13.92±2.59 and 11.44±1.89 respectively, the difference was not significant (P>0.05) according to statistical analysis. The results indicated that acupuncture could improve the sleep quality of patients suffering from malignant tumor, and the effect was better than that of Fluoxetine Hydrochloride capsule.
Table 6. PSQI total scores before and after treatment of malignant tumor patients in the two groups (X + s)
Group Cases Before treatment After treatment
Treatment group 40 14.48±1.71 7.92±1.22*#
Control group 40 13.92±2.59 11.44±1.89
Notes: *compared with score before treatment P<0.05, #compared with control group P<0.01.
DISCUSSION
Depression has a high incidence rate and recurrence rate in patients suffering from malignant tumor. It is very harmful, as the depressed mood affects patients' sleep quality largely. With the development of cancer treatment and surgery methods, cancer mortality declines year by year. However, the depression morbidity is still high. Massie's research indicated that the incidence rate of depression in cancer patients was 1%—50%; severe depression was 0-38%; and depression spectrum complications was 0-58%.10 Depression seriously affects the life quality of cancer patients and reduces patients' adherence to treatment. Moreover, it affects the prognosis and increases the mortality. At the present time, fluoxertine hydrochloride is the antidepressant drug with exact effect and is applied widely in clinical practice. However, it also has adverse effects such as gastrointestinal symptoms, transient increase of anxiety symptoms and sexual disorder.11 Also, there are some limitations of clinical application.
Some researches show that depression is related to hypofunction of norepinephrine and serotonin in the brain. Acupuncture can promote the releases of norepinephrine and serotonin; and can also help
neurological rehabilitation. Thus, acupuncture has unique effect in treating depression.12'13 In addition, acupuncture has the effect of two-way regulation; it can adjust the processes of excitation and inhibition of cortical centre through nervous system and immune system; therefore, it can balance neurotransmitters among neuronal synapses in the brain. Furthermore, it can extend blood vessel, increase cerebral blood flow to improve depression and sleep quality.14
For malignant tumor, pattern of phlegm-stasis binding is the most common type in TCM. In the treatment group, all the patients were treated with acupuncture on the acupoints of Fenglong (ST 40), Yinlingquan (SP 9), Xuehai (SP 10), Sanyinjiao (SP 6), Yintang (EX-HN3), Baihui (DU 20), Sishencong (EX-HN1), Neiguan (PC 6) and Shenmen (TF 4). Acupuncture is mainly used to dissolve phlegm, dispel stasis, quiet the heart and calm the mind. Needling on Fenglong (ST 40) is to harmonize the stomach, dissolve phlegm and clear mind. Needling on Yinlingquan (SP 9) can take effects of resolving dampness and dispelling stasis. Needling on Xuehai (SP 10) is to regulate qi and invigorate blood. For depression, the location of disease is the heart and the brain. According to TCM, when the five zang-organs and six fU-organs get ill, their yuan-source (origin source) points will be chosen for needling. Thus, needling on Shenmen (TF 4), which is the yuan-source point of the Hand-Shaoyin Heart Channel, to quiet the heart and calm the mind; and combined with needling Sanyinjiao (SP 6) to fortify the spleen, sooth the liver and quiet the heart. In this way, sleep can be adjusted. Neiguan (PC 6) is the luo-connecting point of the Hand-Jueyin Pericardium Channel and one of confluence points of the eight extraordinary vessels, which communicates with Yinwei Mai (Yin linked Vessel) with the effects of quieting the heart, calming the mind, rectifying qi and relieving pain. One ancient TCM work Bai Zheng Fu (Essay for One Hundred Patterns) said: "Jianli (RN 11) and Neiguan (PC 6) can dissolve all the discomforts in the chest." Sishencong (EX-HN1), one extra point, can calm the mind. Baihui (DU 20) and Yintang (EX-HN3) can soothe the liver, rectify qi, quiet the heart and calm the mind; they also can improve the symptoms of depression.
The research indicates that SDS score and HAMD score of the treatment group were 43.64±5.28 and 9.88±1.27 respectively after 30 days treatment, which were obviously lower than 50.76±5.42 and 13.72±2.05 of the control group (P<0.05). In the treatment group, PSQI total score was 7.92±1.22 after 30 days treatment, which was obviously lower than 14.48±1.71 before treatment (P<0.05). The results showed that the effective rate was 87.5% in the treatment group and 67.5% in the control group. The therapeutic effects in two groups were significantly different (P<0.05). In summary, acupuncture has a lot of advantages in treating depression of tumor patients; and it is favorable to relieving depression mood and improving sleep quality.
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(Received June 10, 2011)
