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Acupuncture and Schizophrenia –
Effect and Acceptability:
Preliminary results of the first UK study
Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis,
After several years of planning, we have just completed the intervention phase of a small, pre-clinical pilot study to explore the acceptability and effects of acupuncture in the treatment of schizophrenia. The study was carried out in a primary care setting in an inner city setting. It was facilitated by GPs and mental health workers, who helped recruit participants and provided rooms for the research, and highlights a successful collaboration between acupuncture practitioners and academics.
Anecdotal observations and preliminary indications from the statistical data are positive. The qualitative data have yet to be analysed and triangulated alongside the quantitative data. Additionally, these data will be compared with another mixed methods study concurrently being conducted by Peggy Bosch in Germany, and a recent service evaluation from Walsall (Rogers 2009), both of which share two of the same research tools. This article outlines the research question and methods used in this study, and offers a glimmer of the outcomes so far. The European Journal of Oriental Medicine 19 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson using acupuncture over an intervention period of ten weeks. Schizophrenia is a severe and debilitating condition that affects Participants were identified, the study was explained to them and around 1% of the population (McGrath, 2005). Its prevalence is they were asked if they were willing to participate. Acupuncture set to increase, as it is associated with urbanisation and poverty treatment was provided twice a week for ten weeks on an (Pedersen and Mortensen, 2001; Peen and Decker, 1997). The individual basis. The study was drawn up in line with the Medical condition leads to poverty (Lewis et al, 1992), social isolation, Research Council (MRC) framework for complex interventions poor physical health (Lambert et al, 2003), self harm and (MRC, 2000) as a small in-depth study (pre-clinical phase) in order suicide (Pompili et al, 2007). The onset of schizophrenia usually to identify possible outcomes and modifiers to inform future commences in early adult life, affecting most patients for the studies. Data collection methods included: rest of their lives. The mainstay of treatment is antipsychotic medication, with some emerging research showing that Qualitative Interviews to explore issues around their quality of treatment with psychological therapies may be useful in the early life and experience of acupuncture before and after treatment; stages (Dyer & McGuinness, 2008; Lewis et al, 2006; Ross and Positive and Negative Syndrome Scale (PANSS) (Kay et al, 1989 Read, 2004).
and 2000); Schizophrenia Quality of Life Questionnaire (SQLS) (Martin and Allan, 2007; Wilkinson et al, 2000); Pittsburgh Current treatment for schizophrenia is limited and unsatisfactory, Sleep Quality Index (PSQI) (Buysse, Reynolds III et al, 1989); and there is a demand for complementary approaches that might Unstructured Observation of Acupuncture Treatment to confirm improve outcomes (Rampes, 2004). There is some evidence or challenge data being collected elsewhere in the study (Watson available to support the use of acupuncture in schizophrenia (see and Whyte, 2006); Examination of Mental Health and GP Soo Lee et al, 2009; Harbinson & Ronan, 2006; Smith, 1993; Ben clinical notes; Acupuncture Notes: modified protocol, based on et al, 1993). However, most of the research has been carried out the Standards for Reporting Interventions in Controlled Trials in China and it is unknown to what extent the findings might of Acupuncture (STRICTA) guidelines (MacPherson et al, 2002; be replicated in Western countries, including the UK. Moreover, MacPherson et al, 2001). it is unclear what effects might best be measured or how acupuncture might best be administered in the UK (Harbinson & In addition to standard care, participants received individual assessment and treatment with acupuncture, using the traditional Acupuncture is rarely available in the NHS. People with Chinese medicine approach. This included an initial assessment, schizophrenia can rarely afford private treatment. It is unknown followed by twice weekly treatment sessions, each lasting 45 – whether acupuncture will be culturally acceptable in the UK 60 minutes, for ten weeks. The acupuncture was administered for the treatment of schizophrenia (eg, Cardini et al, 2005). by three trained acupuncturists, registered with the British Encouragingly, acupuncture was recently approved as a treatment Acupuncture Council (BAcC) and all of whom had some previous of choice for low back pain by NICE (NICE, 2009). There is experience of working within mental health. The research team clearly a need for exploration of complementary medicine to made contact with the patient's treating doctor or keyworker in improve outcomes for people with schizophrenia who have not order to appraise them of the treatment approach, to ask them had satisfactory results from normal treatment because their to note any significant changes, and to identify any potential risks symptoms have not fully remitted and/or because they suffer or reasons for withdrawal from the study.
from side effects of antipsychotic medication. There are many questions raised by studies already conducted including how a large scale controlled study might best be designed in the UK. Of those who were eligible and invited to take part in the In order to achieve this, this study was designed to gain a more study, eleven participants agreed. All were fluent in English in-depth understanding of how acupuncture could address the and literate and gave informed consent to participate. They problems experienced by people with schizophrenia and its were aged between 18 and 65 and had been diagnosed with acceptability, in order to inform a high quality RCT or complex schizophrenia (ICD10 – F20-25). They had not had complete intervention study. A case study approach is ideal for such an remission of symptoms despite treatment, and/or they suffered investigation and has the flexibility to address questions that have from side-effects of antipsychotic medication. The sample was arisen in reviewing the evidence, as well as those that may arise representative of the local population and gender in terms of during the study (Creswell, 2007; Yin, 2003). demographics of people with this diagnosis. The study was reviewed by the Joint South London and Maudsley and The Institute of Psychiatry NHS Research Ethics Committee. A pre-clinical pilot study examining the effect of acupuncture on eleven participants diagnosed with schizophrenia, utilising both an exploratory and an instrumental case study approach (Stake, 1995; Jones, 2004; Bergen and While, 2000) was carried Eleven participants were recruited to the study. Eight participants out. A variety of methods were used to collect and examine completed the treatment phase as well as all sets of data in-depth information on this population, and the effect of collection. One completed the treatment phase, but was lost to 20 The European Journal of Oriental Medicine Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study follow up. One withdrew after six treatments because he found the needles too painful. One relapsed near the completion of the treatment phase and, although he agreed to complete a final interview, he was not well enough to do so. There are eight complete sets of data. Incomplete sets of data are included in the qualitative analysis. This may provide clues as to potential reasons for drop out and, for those participants who did not complete the study, indications as to whether acupuncture helped at all, if it was acceptable as a treatment and whether their were any common features in their experience.
Figure 1: Flow chart to illustrate the participant experience of this study
Recruitment and Preparation
Information to clinicians and patients Clinicians approach Further information given to patient Data Collection Phase 1 – Week 1 (1st Baseline)
PANSS Interview Carer/Clinician
PANSS Examination of Qualitative interview Data Collection Phase 1 – Week 5 (2nd Baseline)
PANSS Interview Carer/Clinician
PANSS Examination of Qualitative interview Data Collection Phase 2 – Weeks 6-16
Acupuncture Assessment First Acupuncture Acupuncture treatment Researcher observes =/> 2 treatments randomly selected Data Collection Phase 3 – Week 17
PANSS Interview Carer/Clinician
PANSS Examination of Qualitative interview Exclusion Criteria:
• Schizophrenia = secondary diagnosis • Diagnosis of schizophrenia • Acutely psychotic • Able to provide: • Concerns about needles/Needle phobia • informed consent • Learning disabilities • understand, read and write English • articulate own perceptions of symptoms and side-effects The European Journal of Oriental Medicine 21 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson This fell to a final average score of 38, representing a mean fall of 44% to a below average score. These scores need further Positive and Negative Syndrome Scale (PANSS)
statistical testing and triangulation with the qualitative data. Initial testing of significance in terms of Probability or P values is positive.
Schizophrenia Quality of Life Questionnaire (SQLS)
Baseline 1Baseline 2 PANSS total
SQLS total
PANSS is an assessment process that includes examination of mental health case notes and structured interviews with the participant and an identified carer or clinician in order to identify and measure symptom severity and quality of life. Findings are matched to identified criteria and definitions according to a 7-point scale, 1 being equal to ‘absent' and 7 being equal to The SQLS is a self-reporting questionnaire that employs a 5-point extreme. It has well established reliability and validity (Kay et al, Likert Scale (Never, Rarely, Sometimes, Often, Always) to obtain answers to 30 short questions about the side effects experienced from antipsychotic medication and quality of life issues such as The PANSS Institute advise that the Total Score (or T-scores) are smoking, exercise and levels of motivation. It has been shown to the most helpful when comparing a small number of participants. have good reliability and validity in a number of studies (Martin This is an overall indication of the extent of a patient's symptoms and Allan, 2007; Wilkinson et al, 2000). in comparison to 240 medicated patients with a diagnosis of schizophrenia. A guide is that the average T-score is 50, with a Figure 2 illustrates the individual overall scores for SQLS. The total standard deviation of 10. Scores above 70 are very much above score is out of 100, with a high score representing a poor quality average (worse off in terms of symptoms); scores between 66-70 of life and vice versa. The mean score was 56.25 falling to 51.67, are much above average; between 61-65 above average; 56-61 representing an average improvement of 8% for participants. This slightly above average; and so on. This is not a definitive guide suggests that there was no significant change in terms of quality and the Institute advises that individual scores are also examined of life or side effects of antipsychotic medication, although (Kay et al, 2000). This will be carried out as part of the analysis. the qualitative data appear to indicate otherwise (see below). Figure 1 above, indicates that the average Baseline PANSS T- score These scores also need further testing and will be included in for the eight participants who completed the study was 68. 22 The European Journal of Oriental Medicine Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study Pittsburgh Sleep Quality Index (PSQI)
Baseline 1Baseline 2Final PSQI total 5
PQSI Sleep ef 0.5
The PSQI is a self-rated questionnaire that assesses sleep quality, Figure 4 represents data on Sleep Efficiency for all participants. latency (the amount of time it takes to go to sleep), duration, Where there appears to be no data for some participants, their habitual efficiency, disturbance, medication use and daytime score for sleep efficiency was above 85%. This means that dysfunction resulting from poor sleep over the previous month. It they were asleep for more than 85% of the time they were in takes 5-10 minutes to complete and asks respondents to quantify bed. Four of the participants had problems with sleep efficiency, various aspects of their sleep, such as the number of minutes it spending up to 17 hours a day in bed. The average baseline score takes to fall asleep at night (Buysse, Reynolds III et al, 1989). It for these participants was 2.75. This fell to 1.25, representing has been shown to have good reliability and validity in a number a mean fall of 55% for these four participants. Most notably, of studies (Buysse et al, 1989; Grandner et al, 2006; Carpenter & participant no. 5's score fell from 3 (sleep efficiency of less than Andrykowski, 1998; Gentili et al, 1995). 65%) to 0. This participant was unable to get up because he was so distracted by his voices. Again, these scores are subject to Figure 3 shows that the average baseline T-score for the PSQI further statistical analysis.
was 9.44, and the final score was 6.88, indicating a mean improvement of 27% in sleep for all participants. Preliminary All participants reported improvements in sleep and less fatigue, statistical examination of these scores indicates some significance including those who did not complete the final interviews. in terms of P values, but further work needs to be carried out.
It is interesting that the participant who withdrew from the study because of needle pain called several weeks later to say that he noticed he was feeling increasingly tired since the acupuncture stopped, and was sleeping again in the afternoon. He reported that these symptoms had been present before the treatment began and had disappeared during the intervention phase. At the time, he had been sceptical about acupuncture and did not think it was having any effect. Only when these symptoms recurred did he realise that treatment had helped with his tiredness. The European Journal of Oriental Medicine 23 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson Table 1: TCM diagnosis
None of the three acupuncturists who delivered treatment for the study were specialists in the mental health field, nor were we familiar with the assessment tools that were being Liver Depression Qi Stagnation applied. We were to all intents and purposes ‘common or garden acupuncturists' confronted in a modern health centre with a youngish client group who received treatment for free twice a week. Attendance was far better than we had initially Heart-Kidney not Harmonised expected, and it was a real delight to be able to give treatment so Stomach Yin & Spleen Qi Deficiency frequently and for free. Spleen Qi Deficiency generating Dampness We set out to offer individualised treatment, as is our normal Kidney Deficiency/Kidney Qi not Firm practice, and it was interesting that the participants were clear from the outset what they wanted treatment for, even though Phlegm-Fire Harassing the Mind many of them knew little about acupuncture or how it could Liver & Heart Blood Deficiency help. Anxiety was what featured most strongly, followed by pain of various sorts, and then (in no particular order) concerns Liver Yang Rising about sleep, tiredness, lack of motivation, hallucinations, and weight gain. We were free to respond to changes in a patient's Liver & Kidney Yin Deficiency presentation or priorities, so that they got the benefit of having Kidney Failing to Receive Qi old injuries, acute conditions (colds and flu mostly) or newly emerging problems treated. So for example, if a patient who Lung & Kidney Deficiency leading to Phlegm initially declared that she wanted treatment for anxiety and stress, arrived complaining of abdominal pain and tightness at Local Stagnation of Qi & Blood the shoulders, we would tend to treat the presenting complaint on the understanding that it was, to some extent at least, a Each participant often had a number of co-existing syndromes manifestation of the constant anxiety and stress she experienced and therefore a number of diagnoses that needed to be recorded and that relieving it would contribute to a lessening of those non- alongside each other. Typically these included excess and deficient physical symptoms. It was not rocket science, just normal practice.
symptoms. Many of the participants were openly concerned about the voices that harassed them and expressed their dismay, The table below shows the syndromes which we diagnosed frustration, etc. about having to cope with them on a regular following the initial consultation with the patients who had basis. For this reason a diagnosis of phlegm – fire harassing been allocated to us (6 in column A, 5 in B). The researcher the mind could easily coexist with mental-emotional symptoms likes this table because it shows such disparate views of people – which manifested with symptoms of depletion or deficiency – who in Western medicine share the same diagnosis. We suspect, and/or physiologically deficient conditions such as lung or kidney however, that for acupuncturists it will be less startling – these deficiency. This duality was also evident in the tongue and pulse are not diagnoses of the same people after all. It is interesting to analysis. Tongues often displayed signs of heat or stagnation, and note the participants who were most afflicted by hallucination yet pulses were frequently weak. Clearly medication has to be were all in the column B cohort (hence the strong showing for factored in here and it is difficult to accurately assess how much phlegm-fire harassing the mind). When, at the midpoint of the it affects tongue and pulse analysis. Side effects from medication intervention phase, we had a meeting to discuss progress and were also included in the symptoms that participants reported as share thoughts, it was clear how much convergence there was in terms of the type of treatment we were giving, and the points we were using.
24 The European Journal of Oriental Medicine

Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study Fortunately because we were able to treat participants twice a week it did mean that points could be alternate. For instance, points on the front one day and points on the back later in the same week. This approach allowed us to treat the participants in a more comprehensive way than in the typical private arrangement which tends to allow for just once per week.
Because all of the participants had a considerable number of symptoms it was necessary to ask participants to focus on the areas that they found the most pressing, so that those symptoms could be addressed directly. As time progressed and it became evident that some symptoms were beginning to improve we could adjust our point selection accordingly.
Not being specialists, we have no special ‘tricks' to report – the points we used and the treatments given were similar to those we use every day in our regular practices. Additional skills/techniques were used where and when relevant. Apart from body acupuncture, other techniques used included: ear acupuncture, cupping, TDP lamp, relaxation tapes, and ear seeds – usually on the shen men and sympathetic points. After experiencing the ear seeds two of the participants requested them in subsequent treatments. One of the acupuncturists regularly played music or relaxation tapes during the treatments because it was felt this induced relaxation. Music was only played with consent; if participants preferred not to listen to anything, or if they preferred to talk then these requests were accommodated. Nutritional advice was given where it was felt appropriate. One participant was drinking two litres of coke per day (and three coffees) at the start of the study. It was suggested that substituting water for some of the cola would be a worthwhile aim given that this participant had particular urinary problems. A compromise was reached and the urinary situation improved. In another case a salt pipe and lung tea were recommended for a participant who had severe lung problems. Herbal teas of various sorts were dispensed occasionally (and met with some enthusiasm in most cases, even encouraging a couple of participants to begin exploring this concept as an alternative to the usual ‘English' teabags). Advice was also given, when we thought appropriate, in other areas, such as exercise, mental attitudes, breathing techniques, and even on dating (not that we are experts in that particular field!).
The European Journal of Oriental Medicine 25 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson Emerging themes – Table 2: Preliminary analysis of the qualitative data reveals the following:
All of the participants reported feeling tired most or all of Increase in energy was reported by and/or noticeable in 8 of the 11 participants. 7 participants took little or no exercise. 9 participants increased the amount of exercise they took during the study. Diet and weight
Reduced consumption of sweets, cakes, and sugary drinks. * fast food takeaways and ready meals * fizzy drinks of various sorts 2 participants began to cook for themselves. * highly-sugared tea and/or coffee. All unhappy about their weight. Data for weight loss is not yet available.
10 wanted to lose weight.
Some participants did lose weight, but for most it remained the same. 1 wanted to gain weight.
Addictions
8 of the 11 participants smoked.
4 reduced their smoking significantly.
4 regularly drank heavily. 3 participants dramatically reduced their alcohol consumption.
Social Engagement
Few social contacts. Improvements in social engagement reported or noted in 8 of the 11 participants: For most, social contact was limited to immediate family * 7 increased informal social contacts, or a friend or two, or contact with psychiatric services.
* 5 increased engagement in organised group activities* 4 applied for work training schemes* 9 reported reduction in social anxiety and/or increased confidence in social situations. Sex Drive
Only 1 participant has a partner. The remaining 10 5 expressed an increased interest in having a relationship with the opposite sex, and more appeared resigned to being single, or had lost confidence confidence in this respect, exploring methods of attracting a partner.
and/or their sex drive. 1 stopped having hallucinations about being raped. The participant who has a partner reported an increased sex drive and enjoyment of sex. Anxiety and paranoia
10 out of 11 reported feeling anxious.
9 participants reported feeling less anxious (no follow-up data available on the other 2).
10 out of 11 reported paranoia about people (aggression, Significant reductions in paranoia might be found for 3 participants but the data has yet to being laughed at), limiting their social contact and the amount of friends that they had. 6 participants reported auditory hallucinations, and 1 also 5 experienced significant reductions in hallucinations (1 was lost to follow-up).
reported visual hallucinations.
For 2 participants, the voices disappeared completely.
For 4 of them this severely interfered with their daily life. Side effects of antipsychotic medication
Participants seemed to be reasonably well controlled Although the results from the SQLS are poor, in qualitative interviews, observations and to on antipsychotic medication, but reported side-effects the acupuncturists all of the participants reported improvement or complete remission of including tiredness, drooling, staring, grimacing, shaking or jerking, night time frequency of micturition, constipation, indigestion and vertigo.
26 The European Journal of Oriental Medicine Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study Data from the interviews and observations have yet to be analysed. However, there were some notable features and Find out more on changes for participants that will need closer exploration during our website the analysis phase.
Energy: At the outset, all of the participants reported feeling
Acupuncture, Stimulators & Books
tired most or all of the time. Increased energy levels were reported by and/or noticeable in eight of the eleven participants. Many started to get up earlier and began taking up new activities. For example, instead of staying in bed almost all day, they began to be up and about, visiting friends, taking part in classes, starting exercise programmes, etc. One participant's key worker reported how his punctuality and contribution to the groups he was attending had noticeably improved. He was now turning up on time and becoming an active contributor to group discussions and activities. Another participant, who reported that treatment Permenantly Low Prices had made no difference to her energy levels, started going to the gym three times a week. It could be seen that her complexion changed from being quite grey and wan to being more rosy and glowing; her posture improved and she walked with more spring • The most popular plastic handle needle • Suitable for cosmetic acupuncture • Available in plastic handle (B & J type) and all-metal handle (L & LE type) Exercise: At the outset, all but four of the participants reported
that they took little or no exercise. Some were trying to exercise,
but finding it difficult to motivate themselves and carrying out a
minimal amount. During the intervention phase, all except two
of the participants increased the amount of exercise they took.
One began cycling to work every day, another going to the gym,
another took up dance. Of those who did not increase their exercise, one was already exercising daily, but did report more energy. The other simply did not increase her activity because • On-off one touch she was too busy with other things but she did report improved energy levels. If smoke, ashes and odour prevent you from practicing moxibustion don't curtail the healing Diet: Almost without exception, participants subsisted on what
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of various sorts and/or highly-sugared tea and/or coffee (some reported drinking as many as 15 cups a day). Very few of them cooked at all. They often described eating only two small meals a day, but it was apparent that snacking on cakes and other sugary delights was rife, if considerably understated (by no means an unusual phenomenon). Many of them made some dietary improvements during the study – eating fewer sweets or cakes, or drinking fewer sugary drinks. Two participants began to cook for themselves, using fresh ingredients, rather than heating things up in a microwave. In their We stock a wide and up-to-date selection of books, final interviews, people talked about how much they had reduced charts, DVDs and software. Check our website for their sugar intake, and said that they had been too embarrassed to admit at first how much they had been consuming; this was also true of alcohol and cigarettes (see below).
629 High Road Leytonstone, London E11 4PA, Great Britain Tel—+44(0)20 8518 7337 The European Journal of Oriental Medicine 27 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson Weight: Many of the participants reported feeling unhappy
by 10.30 am and is actively engaged in at least three groups as about their weight. All except one (who was trying to increase his well as CBT. He has started playing football and his social anxiety weight after an illness) wanted to lose weight and get fit again. The data for weight loss is not yet available but although at least four participants did lose weight, for most it remained the same. Sex Drive: Only one participant has a partner. The remaining ten
Addictions: Smoking was clearly a deeply ingrained habit - all but are single. Some of them expressed a wish to make a relationship three of the participants smoked. Four managed to reduce their at the beginning of the study. Over the course of treatment, this smoking significantly; for one participant, consumption fell from is a theme that emerged for many of them. One had already 40 a day to three.
begun to join an internet dating site before treatment began. She began to talk to the acupuncturist about this and seemed Four participants also regularly drank heavily during the week. a little more confident about her efforts during treatment. Two of these admitted to smoking cannabis as well. One initially Others became more interested in sex, having a relationship and admitted to drinking eight cans of strong lager or cider (8.5%) exploring methods of attracting a partner. It seemed that all of a day, four days of the week. He stopped drinking almost them wanted to be in a relationship, but had resigned themselves completely during the study and in his final interview said that, to being single, or had lost confidence and/or their sex drive. The prior to the acupuncture, he had actually been drinking in excess participant who has a partner reported an increased sex drive and of eight cans of lager every day, starting first thing in the morning. enjoyment of sex. This surprised her as she had never initiated sex A similar pattern – serious levels of intake every day – was true for before or enjoyed it. One participant had reported hallucinations the other three ‘drinkers' in the cohort. Two dramatically reduced of being raped every night. These disappeared by about Week 5 their consumption during the study, but unfortunately they both relapsed later following a heavy drinking session, and (for one of them) the use of hard drugs as well. Anxiety, Hallucinations and Paranoia: It was clear at the
outset that anxiety features very largely in the lives of the Social Engagement: Six of the eleven participants live alone,
participants, making it something of an ordeal for many to and many have few social contacts or engagements. Of the five venture outside. Many cited it as a priority when asked how they who don't live alone, only one has a partner; the other four (only would like the acupuncture to help. Most participants identified one of whom was under 30 years of age) were still living with benefits in terms of feeling more relaxed and less anxious generally. For example, one participant who had identified anxiety as his priority for treatment said at the beginning of Week 3 of With regards to employment, only one participant has a job, but the study's intervention phase ‘Anxiety? I haven't got none.' He he said he did not socialise with colleagues and tended to isolate said he used to need his friend to take him to the bus because himself at work. Two go to college; of these, one reported being he was too anxious to go on his own, but now he was fine quite sociable, the other preferred not to socialise at college going by himself. Though his anxiety was not magically made to or elsewhere. Two do volunteer work once a week and have vanish, it definitely seemed to have less hold over him, and at the occasional meals with friends. For the others, social contact was beginning of Week 6 he reported that he was feeling ‘a warm limited to immediate family or a friend or two, or contact with glow of contentment, a feeling of content, of peace; no tension psychiatric services. One man limited his contact to his immediate or anxiety.' (It is also interesting to note that the two participants family, and stayed in bed for most of the day. He would try and who were concomitantly undergoing CBT for anxiety both engage in activity groups organised by mental health services, but reported that the acupuncture had helped reinforce the CBT.) rarely managed to get there, and then would be late and find it hard to concentrate. At the outset, five participants reported hearing voices, which for four of them severely interfered with their daily life. One Eight of the eleven participants improved their social contacts, participant, for example, used to stay in bed arguing with the began to engage more actively in work or training, became less voices all the time. All of these participants reported having fewer socially anxious, less worried about what others might think of or no hallucinations as a result of the acupuncture. The PANSS them and more inclined to make social engagements and see scores bear this out.
them through (e.g. arranging to go out with friends for cocktails). All participants tended to be mistrustful of people generally, with They increased activity and interest in work or training, with some many reporting worries about being attacked in the street or beginning to plan how they might get back into work even on a robbed, but they live in a rough inner city area where such things voluntary basis. The man who works full-time is now applying for are not inconceivable. (Interestingly, schizophrenia is associated further training. The man who stayed in bed all day now gets up with urbanisation (Pedersen & Mortensen, 2001).) However, for 28 The European Journal of Oriental Medicine Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study many of them the main anxiety was about letting people get close The major strength of the research approach has to be our to them. They seem to worry that if people got close to them they ability to confirm our findings because we are asking the same would be bullied, abused, jeered at or betrayed in some way. questions in different ways or participants are able to tell us things we're not asking about and we have been able to record As the study progressed we began to realise that most if not all it and compare. The downside is that there is a huge amount of of the participants (seven of the eleven at this preliminary stage data yet to be transcribed and fully analysed.
of analysis) had suffered some violation or trauma during their childhood or early adulthood (e.g. violence in the home, rape, This triangulation also proved advantageous for the people severe bullying at school etc.). In the light of this, we begin to carrying out the intervention as well as for the researcher. For question the extent to which the participants' presentations example, the researcher would very often confirm, having of anxiety and paranoia are rooted in childhood/adolescent observed a treatment, the acupuncturists' impressions of changes experiences and reinforced by their every day living environment. in the patient's bearing or presentation or symptoms. For people If this is the case, how realistic is it to expect significant change? working on their own, and plagued by the perennial ‘Am I That said, the study does reveal some hopeful signs; it is worth making it all up?' doubt, these small reassurances can be very noting that one participant, for example, who had been traumatised as a kid by bullying reported a definite reduction in anxiety and had even found the confidence to go and join a Quantitative Tools: The quantitative tools (PANSS, SQLS and
football club.
PSQI) used presented their own quandaries.
Side Effects of Antipsychotic Medication: All of the
The PANSS requires an interview with the participant's main carer participants seemed to be reasonably well controlled on or keyworker (someone with whom they have frequent contact antipsychotic medication. Although the results from the SQLS and who can give an account of their presentation in the past are poor, many participants reported having fewer side effects, week or fortnight). However, the majority of the participants such as tiredness, drooling, staring, grimacing, shaking or jerking, lived on their own, shared minimal information with those with constipation, indigestion and frequent nocturia.
whom they did live, or who were close to them, and had quite infrequent contact with primary care of mental health services. Some carers refused to take part in the study, or simply did not return calls. The researcher managed to interview one keyworker The Joys of Triangulation: The study approach includes a
who was responsible for four of the study's participants. This myriad of ways to gather similar kinds of evidence. When it keyworker only had regular contact with one of the four; the was designed, to a large extent, we thought we were gathering other three were thought to be stable and neither asked for nor different kinds of evidence through the use of different methods. needed much input. This changed as the study proceeded and For example, the quantitative tools were included to find out participants' motivation increased. They began to request support about symptoms and side effects of schizophrenia and associated from her in terms of group, gym and training referrals, and to treatments, whilst the qualitative tools were designed to find have more contact as their attendance improved. out how people were living their lives and what was important to them or what might change in terms of their quality of life, Three participants had relatives who were happy to take part, diet, exercise and so on. The acupuncture tools (STRICTA) mixed albeit a little anxious about the effect that acupuncture might both quantitative and qualitative methods for the purpose of have. They were able to give general comments about the conveying specific detail about TCM diagnosis and treatment. In behaviour of the participants, (sleeping, lack of motivation and so fact our experience is that participants have told us similar or the on), but seemed to think that their relatives were functioning at a same things through the use of each of the tools.
reasonable level. They seemed unaware of any anxiety, depression or hallucinations being present – symptoms the participants For example, participants have told us that they feel anxious openly talked about in interviews. Advice was sought from a lot of the time, have not a lot of self-confidence, worry the PANSS Institute, who could only advise us to get as much about their weight etc., and they've told us when these things information from as many sources as possible, and to ensure, as have improved. They've told the researcher (a nurse), and the we had planned, that the interviews were moderated. acupuncturists, the same things. And moreover they have tended to blur information and to be specific about information at The SQLS was chosen for its ability to give a quantitative similar time points in the study. So at the beginning they have indication of any changes in the quality of life and side effects been more vague and hidden more detail than they have at the of antipsychotic medication experienced by participants. Results end once they have become more comfortable with both the from their scores indicate no significant changes in either of these acupuncturists and the researcher.
domains. However, all other interviews and observations indicate otherwise. Further analysis will need to explore whether these The European Journal of Oriental Medicine 29 Patricia Ronan, Dominic Harbinson, Douglas MacInnes, Wendy Lewis, Nicola Robinson results need to be seen as a moderator for the positive outcomes emotional support at some point during treatment, and suggests found through other tools in the study, or whether the SQLS that it may on occasion be a positive or cathartic response (see asked the wrong questions for this group.
Quinton et al, 2007). Some of the participants in our study, including one of those who relapsed, did talk about being more The PSQI measures length and quality of sleep. Although aware of their feelings and described this as a positive effect. the results of the PSQI are significant, the answers given on Further analysis and confirmation may reveal more about this participants' questionnaires do not always reflect their true sleeping patterns. For example, one participant wrote that he went to bed at 4am, got up at 12noon and had nine hours sleep. This indicates a sleep efficiency of 112.5%! Moreover, on The analysis for our study has yet to be completed, but early interview, the same participant said that he went to bed around indications are positive. Moreover, the intention of our work was 11pm, and did not get up until 4-6pm, sleeping until at least 2pm. not only to discover whether acupuncture might be helpful for In terms of PSQI, this indicates a sleep efficiency of 50%. schizophrenia, but how acceptable it is. Although the number of participants is small, the outcomes so far are telling us much Needless to say, the analysis needs to be completed and about what is helpful to measure, what tools are useful and, participants will be asked to confirm the correct interpretation of where participants have problems with acupuncture, what their data as part of the process. Findings such as these bring into these are. There are positive indications for improvements in question the usefulness of questionnaires, and reinforce the utility quality of life, symptoms of schizophrenia and side effects of of recorded interviews, where the researcher can make a more anti-psychotic medication (although not those measured by the thorough exploration of what is actually happening. SQLS). Of particular note are motivational and physical health improvements, especially tiredness, sleep and energy. What was Relapses: Unfortunately, one participant relapsed towards
surprising was the sudden increase in interest in being involved the end of the acupuncture treatment and another soon after with normal activities of life, especially in relationships. its conclusion. Both participants had experienced remarkable improvements during the course of treatment. Both had There are more questions to be addressed in the analysis, significantly reduced their alcohol intake and the amount of including acceptability, knowledge about acupuncture generally, time spent in bed, their sleep had improved, they had increased and pain or fear of pain associated with the treatment. Future participation in activities, one had applied for training, both had studies might consider alternatives to needles, such as cupping increased their exercise, and one had managed to move house. and moxibustion. Some of the participants began to investigate It is not clear why they relapsed, however, one of them had been the possibilities of TCM during the study and requested such prescribed a reduced dose of antipsychotic medication and the treatments, believing they might help improve the effect of the other arbitrarily stopped taking it. Both were found to have been acupuncture, or serve as an alternative. drinking heavily prior to the relapse, one had also taken drugs. Both became really paranoid about the acupuncture, expressing The data for this study is presently undergoing analysis and will be
concerns that the acupuncture or the acupuncturist was in some made available in the coming year.
way responsible for their relapse, and maybe to some extent that is true. This study was funded by the British Acupuncture Council and the
Sir Charles Jessell Fund. The needles were donated by Harmony
Both had suffered sexual trauma of some sort in the past and for one of them being treated by an acupuncturist of the opposite Dept. of Social Work, Community and Mental Health
sex became an issue. Both are still recovering from the relapse Canterbury Christ Church University
and we hope, once their recovery is complete, to endeavour to North Holmes Road
find out what they think could have been done to support them Canterbury
It is hard to find an account of people suffering a relapse during or after acupuncture treatment. Kane & DiScipio (1979) had one out of three cases who withdrew early in the study and was clearly unwell. Smith et al (1993) had enormous success, with only one participant being admitted to hospital for three days over seven years. The Chinese studies appear to be conducted in hospitals and report ‘no response' but not ‘relapse' during or subsequent to treatment (see Soo Lee et al, 2009). Our colleague, Neil Quinton, in Walsall, often talks about patients needing more 30 The European Journal of Oriental Medicine

Acupuncture and Schizophrenia – Effect and Acceptability: Preliminary results of the first UK study Ben, Z., Surong, M., Jiang, Y., Changgeng, Q., Wentong, L., Hexiang, X.,
Martin, C.R. and Allan, R. (2007) Factor structure of the Schizophrenia Quality of
Baotiag, Z and Queying, S. (1993) A controlled study of the therapeutic effects
Life Scale Revision 4 (SQLS-R4), Psychology, Health and Medicine, 12(2): 126–134.
of computer-controlled electric acupuncture treatment of refractory schizophrenia, McGrath, J. (2005) Myths and plain truths about schizophrenia epidemiology-The
World Journal of Acupuncture and Moxibustion, 3(4), Dec.
NAPE lecture, Acta Psychiatrica Scandinavica, 111(1): 4-11.
Bergen, A. and While, A. (2000) A case for case studies: exploring the use of case
Medical Research Council (2000) A framework for development and evaluation of
study design in community nursing research. Journal of Advanced Nursing, 31(4): RCTs for complex interventions to improve health.
Miles, M.B. and Huberman, A.M. (1994) Qualitative Data Analysis: an expanded
Cardini, F., Lombardo, P., Regalia, A.L., Regaldo, G., Zanini, A., Negri, M.G.,
sourcebook. 2nd edn. California: Sage Publications Inc.
Panepuccia, L. and Todros, T. (2005) A randomised controlled trial of moxibustion
for breech presentation, BJOG: An International Journal of Obstetrics and
National Institute for Clinical Excellence, Low back pain: Early management of
Gynaecology 112 (6): 743–747.
persistent non-specific low back pain, May 2009, http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf Cresswell, J.W. (2007). Qualitative Inquiry and Research Design: Choosing Among
Five Approaches. 2nd edn. Thousand Oaks, California: Sage.
Pedersen, C. and Mortensen, P. (2001) Urbanisation and schizophrenia,
Schizophrenia Research (suppl. 41): 65-6.
Dyer, J.G. and McGuinness, T.M. (2008). Update on early intervention in
schizophrenia. Journal of Psychosocial Nursing and Mental Health Services, 46(6):
Peen, J. and Decker, J. (1997) Admission rate for schizophrenia in the Netherlands,
Acta Psychiatrica Scandinavica, 96: 301-5.
Gentili, A., Weiner, D.K., Kuchibhatla, M. & Edinger, J.D. (1995) Test-retest
Pompili, M., Amador, X.A., Girardi, P., Harkavy-Friedman, J., Harrow, M.,
reliability of the Pittsburgh sleep quality index in nursing home residents. Journal of Kaplan, K., Krausz, M., Lester, D., Meltzer, H.Y., Modestin, J., Montross, L.P.,
the American Geriatrics Society, 43(11), 1317-1318. Mortensen, P.B., Munk-Jørgensen, P., Nielsen, J., Nordentoft, M., Saarinen,
P.I., Zisook, S., Wilson, S.T. and Tatarelli, R. (2007) Suicide risk in schizophrenia:
Grandner, M.A., Kripke, D.F., Yoon, I. & Youngstedt, S.D. (2006) Criterion validity
learning from the past to change the future, Annals of General Psychiatry 2007, 6:10.
of the Pittsburgh Sleep Quality Index: Investigation in a non-clinical sample. Sleep and Biological Rhythms, 4(2), 129-136. Quinton, N., Ronan, P., Harbinson, D. The challenges faced by an acupuncturist in
psychiatry, Mental Health Nursing, May 2007, Vol 27, No 3: 10-13.
Harbinson, D. and Ronan, P. (2006) Acupuncture in the treatment of psychosis:
the case for further research EJ Oriental Med, Vol 5, No 2: 24-33.
Rampes, H. Mental health and complementary therapies: a research perspective, in
Darnell P, Pinder M and Treacy K in ed (2006) Searching for evidence: complementary
Jones, C. and Lyons, C. (2004) Case study: design? Method? Or comprehensive
therapies research, The Prince of Wales's Foundation for Integrated Health, London.
strategy? Nurse Researcher, 11(3): 70-76.
Rogers, H. Evaluation of the Acupuncture Service at Broadway North Resource
Kane, J. and Di Scipio, W. (1979) Acupuncture Treatment of Schizophrenia:
Centre from Service User and Carer Perspectives, Walsall Service Users Empowerment, Report on Three Cases March. American Journal of Psychiatry, 136(3): 297-302.
Kay, S.R., Opler, L.A. and Fiszbein, A. (2000) Positive and Negative Syndrome Scale
Ross, C.A., and Read, J. Antipsychotic medication: myths and facts, Chapter 9
(PANSS). 2 edn. New York: Multi-Health Systems, Inc.
in Read, J., Mosher, L.R. and Bentall, R.P. in ed. (2004) Models of madness: Kay, S.R., Opler, L.A. and Lindenmayer, J.P. (1989) The Positive and Negative
psychological, social and biological approaches to schizophrenia, Brunner-Routledge, Syndrome Scale (PANSS): rationale and standardisation. BJ Psychiatry, 155 (suppl. 7): Hove and New York.
Smith, M., Atwood, T., and Turley, G. (1993) ‘Acupuncture May Prevent Relapse
Lewis, G., David, A., Andréasson, S., Allebeck, P. (1992) Schizophrenia and city
in Chronic Severe Psychiatric Patients' presented at the International Congress of the life, Lancet, 340: 137-40.
National Acupuncture Detoxification Association, Milan, Italy; October 11-12, 1997.
Lewis, S.W., Davies, L., Jones, P.B., Barnes, T.R.E., Murray, R.M., Kerwin, R.,
Soo Lee, M., Shin, B.C., Ronan, P. & Ernst E. (2009) Acupuncture for Schizophrenia:
Taylor, D., Hayhurst, P., Markwick, A., Lloyd, H. and Dunn, G. (2006),Randomised
A Systematic Review and meta-analysis, International Journal of Clinical Practice, 63 controlled trials of conventional antipsychotic versus new atypical drugs, and new (11): 1622-1633, Nov.
atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or Stake, R.E. (1995) The Art of Case Study Research, Thousand Oaks, California: Sage.
intolerant of, current drug treatment, Health Technology Assessment, May, (10) 17.
Watson, H. and Whyte, R., Using Observation. In: Gerrish, K. and Lacey, A. eds,
Macpherson, H., White, A., Cummings, M., Jobst, K., Rose, K. and Niemtzow,
(2006) The Research Process in Nursing. 5 edn. Oxford: Blackwell: 383-398.
R. (2001) Towards better standards of reporting controlled trials of acupuncture: the
STRICTA statement, Complementary Therapies in Medicine, 9(4): 246-249.
Wilkinson, G., Hesdon, B., Wild, D., Cookson, R., Farina, C., Sharma, V.,
Fitzpatrick, R. and Jenkinson, C. (2000) Self-report quality of life measure for
Macpherson, H., White, A., Cummings, M., Jobst, K., Rose, K. and Niemtzow,
people with schizophrenia : the SQLS, Br. J. Psychiatry, 177: 42-46.
R. (2002) Standards for reporting interventions in controlled trials of acupuncture: the
STRICTA recommendations. Clinical Acupuncture and Oriental Medicine, 3(1): 6-9.
Yin, R.K. (2003) Case Study Research. 3rd. edn. Thousand Oaks, London,
New Delhi: Sage.
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