The interest of psychiatric patients for complementary medicine, such as acupuncture, is stable, but effect studies in psychiatry remain scarce. In this pilot study, the effects of 3 months of acupuncture treatment on sleep were evaluated and compared between a group of patients with schizophrenia (
Interest in complementary and alternative medicine (CAM), such as acupuncture, has increased in popularity in Western societies in the last part of the twentieth century and there has been a continued interest ever since [
In Western psychiatry, a growing consumption of antipsychotic [
Previous research has shown that adherence to treatment correlates negatively with sleep disturbance and depression [
Acupuncture is part of Traditional Chinese Medicine (TCM), which in itself is a form of CAM that is based on thousands of years of practice [
Recent years have seen an increase in trials on particularly depression and acupuncture [
Even less research with acupuncture has been conducted on schizophrenia. Some literature research [
Acupuncture may be beneficial in the treatment of sleep disorders [
This pilot study evaluates and compares the effects of acupuncture on the subjective quality of sleep in long-term patients with schizophrenia and patients with depression. It is a pragmatic trial and a first start to conduct research in an integrative treatment setting in which psychiatric treatment and TCM are combined.
In total the convenient sample consisted of 40 participants (13 men, 27 women). Sixteen of them (10 women, 6 men, mean age was 44.25 years, SD
Overview of the descriptive statistics of the convenient sample.
Schizophrenia (SD) | Depression (SD) | Healthy control (SD) | |||||
---|---|---|---|---|---|---|---|
Total | Waiting list | Acupuncture | Total | Waiting list | Acupuncture | Total | |
Men | 6 | 3 | 3 | 4 | 2 | 2 | 3 |
Women | 10 | 5 | 5 | 12 | 6 | 6 | 5 |
Length of illness | 13.56 (1.59) | 12.63 (5.90)a | 14.50 (7.07)a | 5.94 (1.05) | 4.38 (3.54) | 7.50 (4.41) | 0 |
Age | 44.25 (2.44) | 42.25 (10.99) | 46.25 (8.57) | 50.94 (1.33) | 52.88 (5.59)b | 49.00 (4.54) | 36.75 (12.43) |
According to the one-way ANOVA (groups as between subjects factor) at baseline: aMean is significantly different (
Overview of the medication used by the different groups at the start of the study.
Group | CPZ | Atypical | Typical | SSRI | Tricyclic antidepressives | SNRI and SSNRI | Others |
---|---|---|---|---|---|---|---|
Depression and acupuncture group | Chlorprothixene in 1 patient |
In 2 |
In 2 |
In 4 |
In 3 |
In 3 |
In 2 |
| |||||||
Depression and waitlist group | Pipamperone in 1 patient |
In 1 |
In 1 |
In 4 |
In 2 |
In 3 |
In 2 |
| |||||||
Schizophrenia and acupuncture group | Amisulpride + 1 in 1 patient |
In 8 |
In 3 |
In 0 |
In 1 |
In 1 |
In 4 |
| |||||||
Schizophrenia and waitlist group | Fluphenazine + 3 in 1 patient |
In 8 |
In 3 |
In 0 |
In 2 |
In 0 |
In 4 |
CPZ (Chlorpromazine Equivalents) were calculated using published equivalencies for oral conventional [
SSRI: selective serotonin reuptake Inhibitor, SNRI: serotonin norepinephrine reuptake inhibitor, SSNRI: selective serotonin norepinephrine reuptake inhibitor.
Recruiting limitations resulted in a higher mean age in the depression waiting list condition than in the healthy control group (
The German version of the PSQI [
The needles (AcuPro C, Wujiang City Cloud & Dragon Medical Device Co., Ltd., China) that were used were
The participants in the acupuncture groups were given acupuncture treatment once a week, twelve weeks in a row. Individualized acupuncture according to TCM principles was applied after careful individual diagnosis by a licensed oriental medical practitioner with more than 5 years of clinical experience [
All participants continued with regular treatment including appointments with their psychiatrists; this was not influenced by the project since acupuncture was used as an add-on treatment.
All participants were tested in an experimental testing room in the clinic, by apprentices who were blind to group or time of testing. The healthy control group was tested at T1 (pretest) only. The participants with schizophrenia and depression were tested at T1 and T2 (posttest). After the tests at T1, participants were randomly divided into a treatment and a waiting list condition. The duration of the whole experiment was 13 weeks, which included 12 weekly acupuncture sessions and pre- and post-testing. At the end of the experiment, all participants received a debriefing and were individually informed about their own test results. Patients on the waiting list were given the opportunity to attend acupuncture treatment after T2 if they wanted to. The current study stopped at T2, although acupuncture treatment was given after T2 in order to provide equal treatment opportunities. The patients, however, were not tested afterwards and therefore these data were not included in the study. Moreover, any acupuncture that was provided after the study was part of their normal treatment, not of any study.
Differences between the five groups on the subtests of the PSQI before the start of the treatment were analyzed with a one-way analysis of variance (one-way ANOVA) with groups as between subjects factor, followed by posthoc (Bonferroni) tests. Repeated measures analyses of variance were used to analyze possible differences on the PSQI Total Score and on the subtests of the PSQI pre- and posttreatment (in the four experimental groups), followed by posthoc (Bonferroni)
For more details see Table
Acupuncture points that were used.
Points/patients | D1 | D2 | D3 | D4 | D5 | D6 | D7 | D8 | S1 | S2 | S3 | S4 | S5 | S6 | S7 | S8 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EX-HN-1 | 12 | 12 | 12 | 12 | 12 | 12 | 11 | 12 | 12 | 11 | 12 | 12 | 11 | 12 | 12 | 12 |
DU-24 | 2 | 5 | 5 | 2 | 8 | |||||||||||
DU-14 | 1 | |||||||||||||||
DU-17 | 1 | |||||||||||||||
DU-18 | 1 | 1 | ||||||||||||||
DU-19 | 1 | |||||||||||||||
EX-HN-3 | 5 | 1 | 2 | |||||||||||||
EX-HN-5 | 5 | 1 | 2 | 1 | ||||||||||||
LI-20 | 1 | |||||||||||||||
ST-8 | 10 | 3 | 3 | 9 | 8 | 7 | 2 | 7 | 5 | 10 | 1 | 2 | 1 | |||
ST-7 | 1 | |||||||||||||||
ST-6 | 2 | |||||||||||||||
TB-21 | 1 | 1 | ||||||||||||||
KI-23 | 2 | |||||||||||||||
KI-24 | 1 | 2 | 1 | |||||||||||||
KI-25 | 1 | 1 | ||||||||||||||
KI-26 | 1 | |||||||||||||||
GB-6 | 1 | |||||||||||||||
GB-7 | 1 | |||||||||||||||
GB-8 | 1 | 1 | ||||||||||||||
GB-13 | 2 | 1 | 2 | 1 | 9 | |||||||||||
GB-20 | 2 | 1 | ||||||||||||||
SI-3 | 5 | 11 | 2 | 2 | 1 | |||||||||||
SI-4 | 1 | |||||||||||||||
SI-5 | 2 | |||||||||||||||
HT-2 | 1 | |||||||||||||||
HT-3 | 1 | 4 | 3 | 3 | 1 | 4 | 2 | |||||||||
LI-4 | 12 | 12 | 12 | 12 | 12 | 12 | 12 | 12 | 7 | 3 | 5 | 9 | 10 | 8 | 12 | 4 |
PC-6 | 3 | 2 | 1 | 4 | 2 | 1 | 1 | 2 | 1 | 1 | 1 | |||||
PC-7 | 1 | 4 | 2 | 5 | 4 | 2 | 1 | 2 | 1 | 7 | ||||||
HT-7 | 12 | 12 | 11 | 12 | 12 | 12 | 12 | 12 | 9 | 1 | 7 | 3 | 3 | 8 | 3 | |
HT-8 | 1 | |||||||||||||||
LU-5 | 1 | 1 | ||||||||||||||
LU-6 | 8 | |||||||||||||||
LU-7 | 1 | 11 | 8 | 5 | 3 | 3 | 12 | 8 | 1 | 3 | 5 | 1 | ||||
TB-5 | 5 | 10 | 3 | 2 | 2 | |||||||||||
TB-6 | 1 | |||||||||||||||
LI-7 | 1 | 2 | 1 | 2 | 10 | 2 | 1 | 1 | 1 | |||||||
LI-11 | 6 | 6 | 3 | 12 | 10 | 1 | 12 | 6 | 5 | 10 | 8 | 8 | 8 | 11 | 12 | 11 |
CV-12 | 2 | |||||||||||||||
CV-14 | 1 | |||||||||||||||
CV-15 | 1 | |||||||||||||||
CV-16 | 1 | 1 | ||||||||||||||
CV-17 | 7 | 2 | 3 | 7 | 10 | 1 | 7 | 9 | 12 | 3 | 6 | 9 | 9 | 8 | 11 | |
CV-18 | 2 | 3 | 1 | |||||||||||||
ST-21 | 3 | 4 | ||||||||||||||
ST-25 | 4 | 2 | 1 | 3 | 5 | 1 | 3 | |||||||||
CV-5 | 1 | |||||||||||||||
CV-4 | 3 | 8 | 9 | 2 | 9 | |||||||||||
KI-10 | 1 | 2 | ||||||||||||||
SP-10 | 7 | 6 | 9 | 2 | 3 | 1 | 1 | |||||||||
BL-39 | 1 | |||||||||||||||
BL-40 | 1 | 3 | ||||||||||||||
SP-9 | 12 | 12 | 12 | 12 | 11 | 12 | 12 | 12 | 7 | 6 | 10 | 9 | 12 | 12 | 12 | 3 |
GB-34 | 8 | 7 | 5 | 7 | 8 | 6 | 5 | 6 | 1 | 1 | 4 | |||||
ST-36 | 12 | 12 | 12 | 8 | 12 | 12 | 2 | 12 | 7 | 1 | 3 | 8 | 9 | 8 | 9 | 2 |
ST-40 | 1 | 1 | 12 | 11 | 1 | 10 | 9 | 3 | 2 | 4 | 2 | 9 | ||||
SP-6 | 12 | 12 | 12 | 12 | 12 | 12 | 12 | 11 | 11 | 4 | 12 | 8 | 12 | 11 | 12 | 10 |
KI-3 | 11 | 12 | 12 | 12 | 12 | 12 | 12 | 12 | 1 | 2 | 4 | 7 | 11 | 12 | ||
KI-5 | 2 | |||||||||||||||
KI-6 | 9 | 8 | 9 | 5 | 8 | 12 | 2 | 2 | ||||||||
LR-3 | 10 | 12 | 11 | 12 | 10 | 4 | 7 | 10 | 10 | 9 | 6 | 8 | 10 | 9 | 5 | 7 |
LR-1 | 2 | 2 | 4 | |||||||||||||
SP-4 | 4 | 4 | 1 | 11 | 4 | 7 | 9 | 7 | 1 | 2 | ||||||
BL-60 | 2 | 2 | 1 | 3 | ||||||||||||
BL-62 | 2 | |||||||||||||||
ST-44 | 2 | 7 | 1 | 3 | 7 | |||||||||||
ST-45 | 6 | 2 | 1 | 1 | ||||||||||||
GB-41 | 1 | 1 | ||||||||||||||
GB-44 | 3 | 9 | 6 | 2 | 1 | 5 | 4 | 2 | ||||||||
GB-45 | 1 | |||||||||||||||
BL-67 | 1 | 1 | 6 | 5 | 3 | 2 | 1 | 1 | 11 | 1 | ||||||
Eye of the knee | 8 | 3 | 5 | 6 | ||||||||||||
BAXIE | 3 |
D: patient with depression, S: patient with schizophrenia.
Descriptive characteristics of the five different groups are shown in Table
Corrected means and SDs of the PSQI subtest scores at baseline (T1) for all groups.
PSQI subtest | Schizophrenia | Schizophrenia | Depression | Depression | Healthy (SD) |
---|---|---|---|---|---|
waiting list (SD) | acupuncture (SD) | waiting list (SD) | acupuncture (SD) | ||
Total score | 5.75 (1.91) | 8.50b (4.21) | 9.63b (4.57) | 8.50b (3.02) | 3.50 (2.07) |
Subjective sleep quality | 1.00 (0.76) | 1.00 (0.76) | 1.63 (0.52) | 1.38 (0.52) | 0.75 (0.46) |
Latency | 0.87 (1.36) | 1.88 (1.13) | 1.50 (1.07) | 1.50 (0.93) | 0.50 (0.54) |
Duration | 0.25 (0.46) | 0.38 (1.06) | 1.00 (1.41) | 0.50 (0.93) | 0.63 (0.74) |
Efficiency | 1.38 (1.51) | 1.00 (1.07) | 1.13 (1.55) | 1.00 (1.31) | 0.25 (0.71) |
Disorders | 0.88 (0.35) | 1.38 (0.52) | 1.63 (0.74) | 1.50 (0.54) | 0.88 (0.35) |
Medication | 0.00a (0.00) | 1.88b (1.55) | 1.25 (1.49) | 0.75 (1.39) | 0.00 (0.00) |
Daytime sleepiness | 1.38 (0.52) | 1.00b (0.76) | 1.50 (0.93) | 1.88 (0.84) | 0.50 (0.54) |
According to the one-way ANOVA (groups as between subjects factor) and post hoc tests at baseline: aMean is significantly different (
All patients randomized and treated over 12 weeks in the depression and schizophrenia groups were analyzed (each
Corrected pretest (T1) means of the PSQI for all five groups and posttest (T2) means of the PSQI for the four groups with patients.
PSQI subtest | Schizophrenia waiting list | Schizophrenia acupuncture | Depression waiting list | Depression acupuncture | Healthy control | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
T1 | T2 |
|
T1 | T2 |
|
T1 | T2 |
|
T1 | T2 |
|
T1 | |
Total score | 5.75 | 4.88 | 0.576 | 8.50 | 5.50 | 0.048* | 9.63 | 9.00 | 0.493 | 8.50 | 6.88 | 0.003** | 3.50 |
Subjective quality | 1.00 | 0.75 | 0.170 | 1.00 | 0.50 | 0.170 | 1.63 | 1.50 | 0.685 | 1.38 | 1.00 | 0.080 | 0.75 |
Latency | 0.87 | 0.75 | 0.732 | 1.88 | 0.75 | 0.038* | 1.50 | 1.63 | 0.685 | 1.50 | 1.12 | 0.197 | 0.50 |
Duration | 0.25 | 0.13 | 0.598 | 0.38 | 0.63 | 0.351 | 1.00 | 0.75 | 0.451 | 0.50 | 0.63 | 0.351 | 0.63 |
Efficiency | 1.38 | 0.63 | 0.365 | 1.00 | 1.50 | 0.407 | 1.13 | 1.38 | 0.563 | 1.00 | 0.75 | 0.170 | 0.25 |
Disorders | 0.88 | 0.88 | 1.00 | 1.38 | 0.88 | 0.033* | 1.63 | 1.63 | 1.00 | 1.50 | 1.13 | 0.080 | 0.88 |
Medication | 0.00 | 0.38 | 0.351 | 1.88 | 0.38 | 0.033* | 1.25 | 0.13 | 0.094 | 0.75 | 0.75 | 1.00 | 0.00 |
Daytime sleepiness | 1.38 | 1.38 | 1.00 | 1.00 | 0.88 | 0.685 | 1.50 | 2.00 | 0.104 | 1.88 | 1.50 | 0.080 | 0.50 |
Difference T1-T2 within the groups: *
Two patients reported bruising as a side effect after one of the acupuncture treatment sessions. Moreover, one patient reported having been extremely tired after the first session. Otherwise, no side effects were reported.
In this pilot study, the effects of three months of acupuncture treatment on subjective sleep quality were investigated in a group of patients with schizophrenia and a group of patients with depression that were diagnosed by their therapists according to the ICD-10 [
Three subscales (PSQI Latency, PSQI Medication, and PSQI Disorders) showed significant improvements in the schizophrenia group, but not in the depression group. This indicates that the patients with schizophrenia took more benefit from acupuncture than the patients with depression. Of note, these patients fell asleep faster and even approached normal levels on the subtest (PSQI Latency), meaning that patients with schizophrenia lay awake less long before falling asleep after acupuncture treatment and that they reached levels that are commonly found in healthy controls. They also used less medication in order to sleep and reached normative levels also on the subtest for sleep disorders. Five of the patients with schizophrenia (from the acupuncture condition) used sleep medication of different kinds beforehand, whereas four of them answered that they had stopped using this medication during the time of the acupuncture treatment. Moreover, one of the patients in the waiting list condition of this group, who had not used sleep medication beforehand, started using sleep medication. On the other hand, six of the patients with depression (two in the acupuncture group and four in the waiting list condition) used sleep medication beforehand of which 4 (in the waiting list condition) stopped using this medication and one of the other patients in the waiting list group started to use sleep medication. There were no differences between or within the depression groups on medication use as reported by the patient.
The intervention phase lasted three months (12 treatments) only. Future studies might consider whether the novelty factor of this intervention or the short-term availability implies that patients are more likely to attend. It is not known whether patients would be so keen to attend acupuncture were it available as part of their normal treatment package. There were no withdrawals from the acupuncture or waiting list groups in this study. In this clinic, as part of the normal treatment package, patients can choose to visit treatment groups like, for instance; a psychosis education group, sleep training, depression group, social competency training group or a memory training. All of these groups last 10 to 12 times and have a dropout rate between 30 to 40%. These differences between the regular groups and this study might be caused by the small amount of appointments in the waiting list condition as well as a positive experience in the acupuncture groups. This impression is supported by the absent dropout and the comments made by participants (that reported, for instance: feeling less tired, more relaxed, and better able to sleep), that they were satisfied with the treatment and keen to have it. On the other hand, it is important to note that the participants were largely self-selecting (as they are in every group they attend in this clinic) and therefore more likely to come to the treatments anyway. However, in order to draw more firm conclusions, it would have been better to implement a measure of treatment satisfaction in the study.
Some participants reduced their medication, in consultation with their psychiatrist, as a result of the acupuncture treatment. These participants saw this as a benefit of the acupuncture. Medication reduction is usually seen as positive by patients. It is felt to be a sense of improvement or achievement. It may be that the promise of a reduction in medication through acupuncture may be a motivational factor for attendance at acupuncture treatments. On the other hand, it is important to note that there are possible pitfalls in reducing medication as well. It has been described that patients with schizophrenia who improve through the use of acupuncture and as a result reduce or even stop taking medication may become more vulnerable to breakdown [
Due to the ethical problems related to discontinuing treatment with antipsychotic and antidepressant drugs, patients continued their medication during the study. We have listed the doses in Chlorpromazine equivalents and information on medication that was used in Table
One more limitation of the study is the fact that a second baseline might have been used; it is recommended for future research.
Since the ethics committee required group treatments due to the fact that a practitioner needed to be present at all times, a limitation was that some participants talked to each other before, during, or after treatment sessions. It was not possible to control for the content of these conversations.
Finally, the number of patients in the present study is relatively small. Therefore, in further research it is necessary to increase the sample size, though, despite the small numbers, significant improvements in sleep quality were found.
There is anxiety about giving acupuncture to people with schizophrenia in Europe, since it is not normally practiced and people in psychiatric hospitals are not normally left alone with needles or other dangerous objects. Moreover, anxiety exists about the needles becoming part of hallucinations or psychotic thoughts. For instance, patients might think that they are being radiographic controlled through the needles. The present study further proves that people with schizophrenia can be safely treated with acupuncture and that the use of needles did not evoke negative emotional reactions.
It is important to realize that in this pilot study, positive results were obtained in a group of patients with schizophrenia that have been ill for more than 10 years. Length of illness was analyzed more specifically and it was found that, although there was a difference between the schizophrenia and depression experimental and waiting list groups when it comes to this factor, it did not account for the more significant results in the group with schizophrenia.
It is obvious that the positive outcomes of this pilot study warrant further and larger-scale research, but the tentative conclusion is that the present study shows that acupuncture seems to influence sleep in a positive way in sleep-disturbed patients and seems a suitable add-on treatment in psychiatry, even in patients with long-term depression or schizophrenia.
None of the authors had financial interests in this research.
The authors thank all attending participants for their willingness to participate in this study and the director of the LVR-Klinik Bedburg-Hau: Dr. Marie Brill. She made this research possible and she created possibilities to combine clinical and research work on a daily basis. Furthermore, they thank the following apprentices for their help in testing the patients: Isabell Gladen, Lara Werkstetter, Julia Lennertz, Ines Kirchberg, Lena Groetelaers, Mira Scholten, Astrid Schulz-Elze, Adam Cichon, and Mara Cofalla.