Acupuncture restores brain connectivity and benefits patients with major depression disorder (MDD). Utilizing functional magnetic resonance imaging (fMRI), researchers at the Guangzhou University of Chinese Medicine hospital document that acupuncture significantly increases the connectivity of the corticostriatum to other brain regions, an important brain circuit connection involved in rewards and motivation. In the same investigation, eight weeks of acupuncture treatments significantly decreased depression scores. Based on MRI results and clinical data, Guangzhou University researchers conclude that acupuncture regulates corticostriatal reward and motivation circuitry and improves patient outcomes for patients with depression. [1] 

The investigation examined an integrative medicine approach to care. All patients received fluoxetine, an antidepressant. However, one group received sham acupuncture and another received true acupuncture. The true acupuncture group demonstrated the aforementioned changes in the corticostriatal circuitry and clinical improvements as well. Sham acupuncture did not produce these changes.

MDD and its debilitating symptoms affect a large portion of the global population; MDD presents widespread economic, social, and personal challenges. Antidepressant medications for MDD are used to help stabilize patients but are often problematic due to adverse effects. The authors note that “accumulating evidence has indicated acupuncture combined with antidepressant medication is more effective than antidepressants alone, and is safe, well tolerated, and has an early onset of action.” [2] The addition of acupuncture to an antidepressant medication protocol increases efficacy and speeds the onset of clinical relief.

The researchers investigated acupuncture’s effects on brain networking changes; fMRI scans were used to measure corticostriatal resting-state functional connectivity (rsFC). The researchers mapped rsFC because it shows the patterns and timing of neuron activation in separate areas of the brain. Measuring rsFC allows researchers to reveal the function of a brain region and investigate how disparate parts of the brain are networked together to serve common mental processes.

The results confirm that acupuncture is effective at reducing self-reported depression symptoms compared with sham acupuncture. Additionally, the fMRI results document that acupuncture significantly increases rsFC between the inferior ventral striatum and medial prefrontal cortex, ventral rostral putamen and the amygdala/parahippocampus, and also the dorsal caudate and middle temporal gyrus. Also, acupuncture decreases rsFC between the right ventral rostral putamen and the right dorsolateral prefrontal cortex, right dorsal caudate, and the bilateral cerebellar tonsil. [3]

Increased connectivity of the striatum is important because it receives input from cortical areas activated during activities such as reward prediction and states of motivation. This brain circuitry is critical for an individual’s ability to learn appropriate actions that produce rewards and to have the motivation for selecting those actions. A core characteristic of patients with depression is anhedonia, the loss of interest in pleasurable activities and loss of ability to feel pleasure. The striatum of the brain (in the basal ganglia) is a critical area of the neurological reward circuit and modulates an individual’s ability to predict pleasure, reward, and mediate motivational states.

The researchers note that prior studies confirm that the pathophysiology of MDD is associated with corticostriatal reward circuitry. [4] In this study, investigators examine the effects of acupuncture combined with fluoxetine on the corticostriatal rsFC before and after both real and sham acupuncture treatments. The researchers conclude that true acupuncture achieves “the treatment effect by modulating the rsFC of corticostriatal reward circuits.” [5]

 Study Design
Patients with MDD were recruited through postings in the community. Forty-six female major depressive patients were included based on the following criteria:

• ICD-10 criteria for depression
• Ages 30–60
• Self-Rating Depression Scale (SDS) score
• Montgomery-Asberg Depression Rating Scale (MADRS) score
• Normal cognitive functioning
• Primary school education or higher
• Right handed

Patients were excluded that did not meet the inclusion criteria or that had other conditions such as severe organ damage or psychosis. Pregnant or breastfeeding women were also excluded from the investigation.

Patients completed the Montgomery-Asberg Depression Rating Scale and Self-Rating Depression Scale to assess depression clinical scores before and after the eight week treatment period. In addition, participants had blood tests for liver function using aminotransferase (ALT) and aspartate aminotransferace (AST), and for kidney function using blood urea nitrogen (BUN) and creatinine tests (Cr).

All participants included in the study were given 20 mg of fluoxetine before being randomly assigned to verum (real acupuncture) or sham acupuncture groups. The researchers note that prior studies indicate that acupuncture treatment combined with antidepressant medications is more effective than antidepressant monotherapy. [6], [7], [8] The fMRI scans were taken before and after eight weeks of acupuncture treatments to map rsFC changes over the intervention time period.

 Acupuncture Protocol
Abdominal acupuncture was chosen for the style of treatment for several reasons. The authors note that research shows that abdominal acupuncture is effective for treatment of depression. They add that it is relatively painless and accepted by patients. Additionally, the rationale for this style includes that “CV8 (umbilicus) plays a crucial role in propelling and regulating the flow of Qi… thus, the acupoints around CV8 in the abdomen may regulate the flow of Qi more efficiently.” [9]

The acupuncture point prescription harmonizes the zang-fu organs, tonifies qi, and replenishes blood. The specific acupoints in the protocol are Zhongwan (CV12), Xiawan (CV10), Qihai (CV6), Guanyuan (CV4), Shangqu (KD17), Huaroumen (ST24), and Qipang (extra point).

Acupuncture needles (0.22 mm × 40 mm) were inserted to a depth of 15–20 mm and were retained for 20 minutes. Sham acupuncture was performed at the same acupoints, but plastic needle tubes absent the presence of any needles were tapped against the skin. The acupoints in both groups were covered for blinding purposes. Acupuncture was administered once a day for three days, and then once every 3 days for the rest of the 8-week intervention.

 Summary
The focus of the investigation was to examine the patterns of rsFC affected by acupuncture treatment. The fMRI imaging confirms that acupuncture increases connectivity of the corticostriatum to other brain regions and is associated with decreased depression symptoms. Specifically, acupuncture significantly increases rsFC of corticostriatal reward circuits and decreases rsFC of the striatal-cerebellar regions. The researchers conclude that acupuncture treatments exert their effective action by modulating the corticostriatal reward and motivation brain circuitry in patients with MDD. Patients interested in learning more about acupuncture treatments are recommended to contact a local acupuncturist.

 

References:
[1] Wang Z, Wang X, Liu J, Chen J, Liu X, Nie G, Jorgenson K, Sohn KC, Huang R, Liu M, Liu B, and Kong J. “Acupuncture treatment modulates the corticostriatal reward circuitry in major depressive disorder.” Journal of Psychiatric Research, 2017; 84:18–26.
[2] Ibid.
[3] Ibid.
[4] Bluhm R, Williamson P, Lanius R, Theberge J, Densmore M, Bartha R, Neufeld R, Osuch E. Resting state default-mode network connectivity in early depression using a seed region-of-interest analysis: decreased connectivity with caudate nucleus. Psychiatry Clin Neurosci. 2009; 63:754–761.
[5] Wang Z, Wang X, Liu J, Chen J, Liu X, Nie G, Jorgenson K, Sohn KC, Huang R, Liu M, Liu B, and Kong J. “Acupuncture treatment modulates the corticostriatal reward circuitry in major depressive disorder.” Journal of Psychiatric Research, 2017; 84:18–26.
[6] Naranjo CA, Tremblay LK, Busto UE. The role of the brain reward system in depression. Prog Neuropsychopharmacol Biol Psychiatry. 2001; 25:781–823.
[7] Pizzagalli DA, Holmes AJ, Dillon DG, Goetz EL, Birk JL, Bogdan R, Dougherty DD, Iosifescu DV, Rauch SL, Fava M. Reduced caudate and nucleus accumbens response to rewards in unmedicated individuals with major depressive disorder. Am J Psychiatry. 2009; 166:702–710.
[8] Chan YY, Lo WY, Yang SN, Chen YH, Lin JG. “The benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis.” J Affect Disord. 2015; 176:106–117.
[9] Wang Z, Wang X, Liu J, Chen J, Liu X, Nie G, Jorgenson K, Sohn KC, Huang R, Liu M, Liu B, and Kong J. “Acupuncture treatment modulates the corticostriatal reward circuitry in major depressive disorder.” Journal of Psychiatric Research, 2017; 84:18–26.
[10] Wang X, Wang Z, Liu J, Chen J, Liu X, Nie G, Byun J-S, Liang Y, Park J, Huang R. “Repeated acupuncture treatments modulate amygdala resting state functional connectivity of depressive patients.” NeuroImage: Clinical. 2016 In press.
[11] Zhang WJ, Yang XB, Zhong BL. “Combination of acupuncture and fluoxetine for depression: a randomized, double-blind, sham-controlled trial.” J Altern Complement Med. 2009; 15:837–844.