Acupuncture, Chinese Herbal Medicine and Kanpo in York

Research Interests

I have been actively involved with research for the past eight years since the MSc at Westminster. I undertook two research projects during the masters programme there. The first one looked at practitioner's conceptualisations and working practice in relation to the Chinese medical concept of 'xie', and I worked on this project with Vivienne Lo. The second project explored patients' explanatory models of acupuncture. For the past six years I have been working on the the challenge of designing clinical trials of acupuncture that have good 'model validity' and are therefore useful and meaningful for patients and service comissioners. Model validity essentially means the intervention under investigation resembles clinical practice and takes into account the sort of outcomes that patients and practitioners expect and hope for.

Using the Medical Research Council framework for the evaluation of complex healthcare interventions, and focussing specifically on acupuncture and depression. With the help of others, I designed and conducted preliminary research (phases I and II of the MRC framework) to inform the design of a full scale clinical trial. I am extremely concerned about the trial that has come out of my research at the University of York (the ACUDEP trial), and is being funded by the NIHR, and have raised my concerns with the trial team. No one involved with the design of the full scale trial has spoken to me about the pre-trial research, which I worked on for six years, in order to develop a full scale trial. I have not been shown a trial protocol but have heard rumours that the study will be investigating 12 sessions of acupuncture and comparing this with 12 sessions of counselling. If this is true then I am concerned that this level of treatment will be insufficient for the trial population (should this be similar to the pilot study) where the majority (nearly 90%) of participants were severely depressed (according to the Beck Depression Inventory). Not only were the majority of study participants severely depressed at baseline, the majority (60%) had suffered with three or more illness episodes (which suggests a poor prognosis), and had a long history of illness spanning more than twenty years in many cases (mean age of onset of first episode was 23 whilst mean age at baseline was 41). Depression was not the only concern for this trial population: 82% had other health problems with the majority (62.5%) using medication for other health conditions in the four weeks before baseline. Seventeen individuals (42%) had five or more health problems apart from depression. Very few patients achieved remission in the pilot study, although there was a greater trend for improvement with both acupuncture and non directive counselling patients, in comparison to usual care alone. Numbers were too small to be certain that this trend was not the result of chance but, it seems likely, given the clinical results of the pilot study, that longer durations of therapy, with some sort of follow up care - in cases where improvements were shown, would achieve better outcomes with both interventions, especially in the long term. Evidence suggests that brief counselling interventions do not show long term benefits.

I am also concerned that a trial comparing 12 sessions of acupuncture and counselling may, based on the results of the pilot study, favour acupuncture. To be a fair comparison both interventions should have an equal chance to work. The main trial counsellor in the pilot study predicted that patients might, as a result of counselling, worsen, before showing improvements. There is a simple and credible explanation for a temporary worsening of symptoms for patients receiving brief counselling - who are severely and chronically ill: patients may feel more vulnerable as they start to open up and talk about difficulties and problems - especially if the circumstances that have led to their depression were experienced as traumatic. The counsellor was sufficiently concerned in one case to provide a further six sessions to a patient who was felt to be at risk if the therapy was prematurely terminated after 12 sessions, and accurately predicted a worsening of symptoms in another case, who improved after further therapy sessions.

My recommendation would be for a full scale trial to compare acupuncture and counselling in a way that did not favour one therapy over the other, and make sure counselling has as much of a chance to work as acupuncture. Better short term and long term outcomes are likely to be achieved with longer courses of treatment for both interventions with patients who are seriously ill. It is a false economy, and more importantly, not in the best interests of patients' welfare, to evaluate inadequate care.

I encourage anyone who reads this email, (especially patients suffering with depression), who would prefer to see a trial that investigates more suitable durations of therapies to contact the NIHR, who are keen to involve patients in the research process and to hear their views about projects they have funded.

Acupuncture, Chinese Herbal Medicine and Kanpo in York - Sylvia Schroer