Depression is a common problem that is disabling, costly and often under treated (Candy, Jones, Williams, Tookman, & King, 2009). As the largest source of non-fatal disease burden in the world, it accounts for 12% of years lived with disability and is associated with marked personal, social and economic morbidity, loss of functioning and productivity (Churchill et al., 2012, NICE 2009 in MacKinnon, 2013).

Clinical practice guidelines for the treatment of depression recommend antidepressants, cognitive-behaviour therapy (CBT) and interpersonal psychotherapy (IPT) as potentially effective interventions (APA 2000; NICE 2004; RANZCP 2004 in MacKinnon, 2013). However, there is a large gap between recommended best practice and what people with depression actually receive.

Literature Review for Acupuncture & Depression

Acupuncture for depression has mixed reviews; positive, inconclusive, and those that claim similar benefits as achieved by pharmacotherapy. Acupuncture combined with pharmacotherapy is a suggested treatment option for depression and acupuncture could reduce adverse side effects from pharmacotherapy for depression.

Current evidence from Stub et al.’s (2011) meta-analysis of four systemic reviews and twenty-six randomised controlled trials (RCT) shows that acupuncture reduces the severity of depression and that TCM and electroacupuncture (EA) may have similar effects as standard care.

More recent trials are investigating a combination of pharmacotherapy and acupuncture. Liu, Lu and Wang (2009) found that EA reduced the side effects that fluoxetine can cause like dry mouth, constipation, dizziness and headache while Duan, Tu, Jiao and Qin (2011) investigated a combination of EA and fluoxetine and reported a significant improvement in the Hamilton depression scale (HAMD) scores. Acupuncture and a low dose of fluoxetine was found to be as effective as the recommended dose of fluoxetine (Zhang, Yang & Zhong, 2009). There was also improvement to the side effects using the combined approach. Two other trials using a combination of acupuncture and paroxetine found that patient’s depression symptoms improved, especially their somatic symptoms and adverse effects from the medication (Guo, Wang, Sun, Zhang, & Ma, 2012; Zhang et al., 2007). In a study of 176 cases of depression treated with acupuncture and Prozac, the therapeutic effect was better or similar to Prozac with less side effects (Fu et al., 2009).

One meta-analysis of acupuncture for MDD (Zhang et al., 2010) involving twenty high quality RCTs found that the efficacy of acupuncture was comparable to antidepressants alone in improving clinical response and alleviating symptom severity of MDD.  Adverse events from acupuncture were significantly lower than antidepressants. Smith et al. (2010) also reviewed acupuncture for depression with an analysis of thirty trials and 2,812 participants. A high risk of bias was found in the majority of trials which concluded in their being insufficient evidence. Two trials showed improvement of acupuncture and medication compared with medication on its own (Smith et al., 2010).

Diverticulosis refers to the diverticula in the intestines, small pouches or sacs that represent herniations of mucosa and sub mucosa in the muscular layer of the colon (Thaha & Williams, 2012). Diverticular disease is classified as ranging from: asymptomatic; symptomatic, uncomplicated diverticular disease; and complicated diverticular disease. The latter includes diverticulitis which can lead to abscess or perforation of the bowel. Other complications include haemorrhage, segmental colitis, peritonitis and fistula.

Between 40-60% of people over 70 years have diverticulosis (Martel & Raskin, 2008) and in older adults there is a female predominance (Thaha & Williams, 2012).

In WM, diet recommendations are made for an uncomplicated presentation of diverticulosis and bulking agents like Normacol are prescribed for associated constipation. With complications including diverticulitis, antibiotics or anti-inflammatory medication are prescribed. New research is emerging about probiotic use.

Prevention is recommended by increasing dietary fibre with fruits and vegetables, limiting red meat and salt and regular physical activity (Thaha & Williams, 2012). In the past, people with diverticulosis were advised to avoid nuts, popcorn, and seeds to reduce the risk of diverticulitis yet this restriction is not evidence-based (Beitz, 2004).

Normacol is prescribed as a laxative yet precautions are necessary in the elderly with prolonged use and abdominal cramp or distention could result (Mims, 2013).

Due to a lack of TCM research under diverticular disease or diverticulosis (appendix 1 for search strategy), the search was widened to include TCM treatment of individual symptoms including; constipation, diarrhoea, bloating and abdominal pain. The research seen as the most relevant to this case was about colon motility and constipation due to its involvement in diverticular disease.

St-36 zusanli has been found to accelerate colonic transit and stimulate distal colonic motility using electro-acupuncture (EA) (Diehl, 1999; Iwa et al., 2006; Takahashi, 2006).

In a systematic review of TCM’s treatment of constipation, significantly positive results were found in 15 of 21 studies (Lin et al., 2009). Of the 21 studies, 18 were Chinese herbal medicine and 3 acupuncture. The results ‘should be interpreted cautiously’ due to the heterogeneity in diagnostic procedures and interventions and differing outcome measures.

In a review of trials using auricular therapy for constipation it was effective in managing constipation(Li, Lee, & Suen, 2010). Generalisation of this result was difficult due to the inconsistent intervention protocols and uncertainty regarding point location accuracy and subject compliance.

Case Study:

After six treatments, a 78 year old patient was able to reduce her use of normacol (under GP guidance) and had a bowel motion almost daily. After twelve treatments she said that with occasional pain she ‘did not let it get me down’ and would think ‘I can make it’ whether she had pain or not. She resumed all her activities and was confident to plan a holiday. She continued to have treatment every 2-3 weeks for the rest of the year with occasional bouts of abdominal pain and stool irregularity. Now, five years later when asked her about diverticulosis, she replied ‘I don’t even think about it’.

Irritable bowel syndrome (IBS) is a chronic condition affecting between 10-15% of the population (Grundmann & Yoon, 2010) with multifaceted possible causes in both western medicine (WM) and traditional Chinese medicine (TCM). It is not considered life threatening yet, as it is chronic and episodic, it impacts on health-related quality of life (Holloway, 2010; Ruepert et al., 2011).

IBS is characterised by abdominal pain, bloating and altered bowel dysfunction resulting in diarrhoea or constipation (Snyder, 2012) and in significant impairments of functional status, higher levels of disability and increased frequency of physician visits (Zijdenbos, de Wit Niek, van der Heijden Geert, Rubin, & Quartero, 2011).

Acupuncture was considered significantly more competent than pharmacological therapy and no specific treatment (Manheimer et al., 2012). Herbal medicine treatment of IBS is looking promising for the treatment of IBS yet it is too premature to make recommendations (Liu, M, Liu, ML, & Grimsgaard, 2011).

A recent trial involving 233 participants with IBS looked at the use of 10 weekly individualised acupuncture sessions plus usual care or usual care alone (Macpherson et al., 2012). Usual care referred to treatment with their medical doctor and the use of prescription medication and outcome data was collected for up to 12 months. There was a statistically significant difference between the groups IBS symptom severity score (IBS-SSS) favouring acupuncture and usual care which suggests that acupuncture could be considered as a treatment option alongside primary care (Macpherson et al., 2012).

In a systematic review of 75 trials investigating herbal medicine including TCM, Tibetan, and  Ayurvedic medicine, they are assessed as being ‘promising for the treatment of irritable bowel syndrome’ (Liu et al., 2011).