Acupuncture, counselling or usual care for depression and comorbid pain.
A new study has examined whether acupuncture or depression have benefits in treating depressed patients with pain compared to the usual care for depression – and concluded acupuncture is the best intervention for depression and pain.
Around 50 – 66% of depressed patients also report pain. We know that depression accentuates existing pain problems adding to the emotional distress and poor sleep irrespective of whether the pain has a known cause. Greater pain may reflect more severe depression. There is a vicious cycle here in that we experience pain more deeply when we are depressed, and may be more emotionally distressed by it whilst pain in itself can be a depressing experience. If the pain limits our ability to function on a daily basis then it can be a trigger for depression. Pain is known to limit routine activities in 42% of primary care patients in the UK prior to starting drug treatment for depression. According to the researchers of this trial:
Too frequently there is a focus on the treatment of either pain or depression. The use of complementary therapies alongside conventional treatments for depression is widespread; this uptake may be attributed to the perceptions of ineffectiveness to patients, the distress of continued symptoms and the unwanted side effects of medication. Treatment outcomes may be enhanced by taking a holistic approach, and delivering treatment options that address both pain and depression together.
A meta-analyses of 18 000 participants data from 25 high-quality trials has shown that acupuncture is an effective treatment option for several chronic pain conditions. Acupuncture is also regularly provided by acupuncturists as a treatment option for depression, though not routinely available as an option for depression within the UK’s National Health Service (NHS). Counselling for depression is widely available in primary care practices, however there is limited evidence for counselling compared to usual care as a treatment for patients with depression and a chronic physical health problem. A recent randomised controlled trial of acupuncture or counselling provided to patients with depression found that both interventions significantly reduced depression at 3 months when compared to usual care. Pain was a secondary outcome in this trial, but has not yet been reported, and it will be of interest to compare the treatment outcome of patients who had comorbid pain and depression with those who had depression alone.
755 patients were recruited from general practices in rural and urban areas of Yorkshire, County Durham and Northumberland. They were randomly allocated to 3 groups: acupuncture (302), counselling (302) or usual care alone (151). The primary aim of the study was to find whether people with depression who are also in pain have better or worse depression outcomes than those without pain. To that end patients were divided into 2 groups – a group with no pain compared to reported either moderate or extreme pain (as a single group).
Participants allocated to the acupuncture and counselling groups received the offer of up to 12 sessions on a weekly basis. The acupuncture intervention was performed according to a treatment protocol developed and agreed by acupuncture practitioners, which allowed for individualised treatment within a standardised theory-driven framework. The acupuncturists were members of the British Acupuncture Council – the leading professional body for lay acupuncturists in the UK. Further details of the acupuncture protocol can be found on this link. The treatment protocol for the counselling intervention was based on competences independently developed for Skills for Health within National Occupational Standards for Psychological Therapies. Usual care available to all participants throughout the trial included prescribed pharmaceutical and other interventions provided by NHS primary or secondary mental health services.
The primary endpoint was at 3 months, with further follow-up at 6, 9 and 12 months.
In terms of health and employment, 56% of the pain group (vs 9% of the no-pain group) reported a painful health condition or illness that predated the onset of the depression, for which 64% (vs 31%) used analgesic medication regularly. 32% (vs 9%) were unable to work or were retired.
Conclusion – acupuncture best for depression with pain.
Patients who had moderate-to-extreme pain comorbid with depression at the start of the trial recovered less well, as expected, when compared to those who were pain free.
Over 3 months, larger reductions in depression and pain scores were found in those who received acupuncture compared to those receiving counselling, and in turn these were greater than those receiving usual care. For those in pain at the start of the trial both acupuncture and counselling delivered a clinically meaningful reduction in bodily pain over 12 months.