Acupuncture and depression: developing a programme of research Hugh MacPherson Sylvia Schroer

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Acupuncture and depressiondeveloping a
programme of research Hugh MacPhersonSylvia
Schroer

• Department of Health Sciences
• University of York
• Foundation for Traditional Chinese Medicine
• York

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Depression the burden

• Third most common reason for consulting in
  primary care
• Economic burden 9 million pa in UK
• 60 patients discontinue medication
• Limited alternatives in primary care

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Acupuncture and depression

• Widespread use in the UK
• 50-60 of acupuncture consultations are
• higher than any other CAM
• Suggestive evidence
• 3 RCTs in China acupuncture equivalent to
  tricyclics
• 3 RCTs in the West mixed results
• Thomas KJ. Nuffield Report 1990.

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The programme at York
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Identifying the therapeutic niche

• Where might acupuncture fit in as a referral
  option in primary care in a way that is
  acceptable to GPs, patients and acupuncturists?
• - How is it currently being used?
• - What gaps can be identified in primary
  care?

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Identifying the therapeutic niche

• Related projects
• -Explore how acupuncturists treat depression
• -Identify broader outcomes of acupuncture valued
  by patients and practitioners
• -Investigate what factors will influence GP
  decision making in terms of referral

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Identifying the therapeutic niche

• Methods
• In depth interviews with GPs, acupuncturists and
  patients
• Use Kleinmans explanatory models to
  contextualise and compare differing
  perspectives- professional (orthodox),
  alternative (traditional), lay (popular)
• Analyse data using Framework

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Identifying the therapeutic niche

• General Issues include-
• Recruitment how to secure participation
• particularly with GPs
• Duration of interviews
• Sensitive topics e.g. therapeutic failure
• Sampling - needs to be sufficiently
  representative, not just
• sympathetic GPs,
• positive patients

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Identifying the therapeutic niche

• Topic Guides
• GPs
• Acupuncture practitioners
• Acupuncture patients with depression

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An RCT treatment protocol

• Key requirements
• Replicability
• Comprehensiveness
• Acceptablity
• Deliverability

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General RCT design choices

• Flexibility spectrum?
• Standardised treatment protocol vs.
  Individualised treatment protocol
• Pre or post trial?
• Pre-trial treatment manual vs.
  Post-trial description

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Pre-trial protocol some challenges

• Practitioner variability
• Different styles of acupuncture
• Different repertoires within each style
• Idiosyncratic practitioners
• Auxiliary techniques self help advice
• Patient variability
• Differ with same condition
• Differ in self-healing response
• Differ in level of partnership

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Two styles of acupuncture

• Traditional Chinese Medicine (TCM) is
• Dominant style of acupuncture internationally and
  the UK
• Is the most researched style
• Five Element acupuncture is
• Practised by 57 of UK practitioners often
  integrated with a TCM approach
• Is argued to be better suited to treating
  emotional/psychological conditions
• No research tradition

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A consensus treatment protocol What is the best
process?

• Reviewing the literature
• Eliciting expert opinion - within styles?
• Proposing a protocol - based on repertoires?
• Using a quantitative consensus process
• Delphi?
• Nominal group technique?
• Testing with regular practitioners
• Comprehensiveness
• Acceptability

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Broader outcomes

• Do existing outcome measures measure the full
  benefits of treatment?
• research suggests they may fall short
• How can we capture and measure the broader
  outcomes?

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Broader outcomes

• 1. In depth interviews
• use the therapeutic niche qualitative research
  as starting point to identify what the results of
  acupuncture are perceived to be and what changes
  would be desirable in context of depression
• 2. Literature review
• disease specific, health status, QOL, economic,
  medication change
• other existing measures that may adequately
  quantify the changes not captured by the above
  measures

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Broader outcomes

• 3. Survey of acupuncture patients
• to test measures of health status, medication
  change and broader outcomes at baseline and 4
  months, is there a shortfall?
• Questions will ask about perceived changes (as a
  result of treatment), is there a shortfall that
  none of the measurement tools are capturing?

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Broader outcomes

• Survey issues
• Sample - should survey focus only on patients
  with depression or on a sample of all acupuncture
  patients?
• Length of survey time between baseline and
  outcome?

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Therapeutic relationship

• Is it important?
• Can we define it?
• Can we measure it?
• How would this be useful?
• Replicability
• Deliverability

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What patients value about the therapeutic
relationship

• Patient survey (n72) and interviews (n11)
  found patients valued
• Treatment effects on symptoms
• Close working relationship
• General health maintenance
• Reference Gould AJ, MacPherson H, 2001
  Patient perspectives on outcomes following
  treatment with acupuncture. Journal of
  Alternative Complementary Medicine, 7(3)
  261-8.

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How practitioners see the therapeutic relationship
What the patient brings
Impact of acupuncture treatment
What happens in the way of a partnership
What the practitioner brings
Based on MacPherson H, Thomas K, et al. in
preparation
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Measuring components and their associations

• Component approach For example, 2002 survey of
  141 patients
• Empathy is associated with
• Enablement, which in turn is associated
• Outcome
• Can we go beyond this?
• Reference MacPherson, H, Mercer S, Scullion T,
  Thomas K. Empathy, enablement and outcome an
  exploratory study of acupuncture patients
  perceptions. J Alt Comp Med. 2003 9(6) 869-76.

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Therapeutic relationship within an RCT what
about ..

• Identifying a measure of the therapeutic
  relationship
• Within an RCT, assessing this relationship as
  well as changes in outcome
• Identifying if there is an interaction between
  the therapeutic relationship and outcome (i.e. is
  it an effect modifier, thereby providing evidence
  of synergy)

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Enhancing likelihood of implementation GPs
prior views
The degree to which a trial of acupuncture can
convince GPs and influence their decisions to
refer patients with depression for acupuncture
will depend on prior views and characteristics
of the trial (e.g. sample size, comparison group,
outcome measures, effect size).
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Enhancing likelihood of implementationGPs
posterior probabilities
Using Bayesian methods, we will carry out a
face-to-face survey of GPs to establish their
prior probabilities of referring to acupuncture
and their posterior probabilities after
presenting a range of hypothetical trial results.
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Enhancing likelihood of implementation a
quantitative measure
This will be used to estimate a quantitative
measure of the influence of these characteristics
on referral decisions (the likelihood ratio).  
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Enhancing likelihood of implementation
optimising trial design
These findings will help us optimise the
design for the Phase 2 RCT and predict the
likely effect of such trials after their results
are known.