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During the course of 2007 it became clear through Community Mental Health Team meetings that a number of staff had chronic anxiety/depression patients who required a very high level of input. This group was characterised by high service use, resistance to medication regimes, resistance to “talking therapies” such as cognitive behavioural therapy (CBT), long, unbroken involvement with the Mental Health Service and both staff and patient feeling “stuck”.
It was decided to form a support group to try to deal with these resource-intensive individuals. Inclusion criteria were discussed and defined as: >1 year of involvement without improvement; >2 forms of medical management without effect; experienced CBT without effect; daily or near daily contact with Mental Health Services; and both patient and service user feeling they had run out of options.
The group recruited four individuals out of those identified in discussions within the Community Mental Health Team and invited them to attend. Two of the subjects had been static for >2 years, the other two >1 year. The design was loosely CBT, with thought processes challenged and corrective methods of thinking reviewed as potential agents of change. The most recent Hospital Anxiety and Depression Scale (HADS) scores prior to treatment were: patient one—A8, D6, patient two—A15, D12 and patient three—A13, D15. The fourth patient, who subsequently left the group, had no recent HADS scores. HADS scores of 0–7 are “normal”, 8–10 “borderline” and 11+ “significant”,1 therefore all patient’s demonstrated borderline or significant clinical indicators. HADS scores were to be collected at baseline and conclusion, but this did not occur.
During the course of the support group sessions, methods of physically managing their symptoms were discussed, and all members of the group expressed an interest in acupuncture. As this point a literature review was conducted and the excellent Pilkington et al article was identified.2 This was used in conjunction with other articles3 4 in developing a treatment regime.
The main problem was that the articles described varying locations, frequency and duration of treatments, and failed to offer any guidance as to why you would chose one of over 30 points over another, beyond the recurring phrase “practitioners experience”. Unfortunately the point that occurred with the greatest frequency, GV20 was dismissed as an option due to the levels of anxiety exhibited in this group.
The points selected were all used bilaterally for a systematic effect, being:
LI4—Large intestines are believed to house Qi.
LI11—depression and mania.
HT7—anxiety, hysteria, mania and palpitations.
The rationale for selecting these points were that they were all acknowledged points, with a reasonable frequency of repetition within the articles examined, they were in areas that required the minimum of undressing (which would decrease the anxiety experienced and allow for a group setting throughout for support mechanisms), and would allow the participants to remain seated with footstools to encourage relaxation throughout.
The design consisted of six sessions over six weeks, 20 minutes initially to assess patient’s reaction, increasing to 30 for the remaining five sessions. A strong de qi sensation was achieved through use of 0.20 mm×25 mm sterile, single use copper handle needles inserted to a depth of 1–3 cm and maintained through manual stimulation. The patients were treated as a group at their request. One patient dropped out for personal reasons after the second session, but the remaining members completed the course. No adverse effects were reported
The patients symptoms were assessed using a visual analogue scale (VAS), with 0 as the “worst” they have ever felt and 10 being the “best”. The VAS results are shown in fig 1.
The most important note that must be made is that the participants in this group felt as if they had improved. In all individuals this was manifested in different ways. One had engaged in the social life that she had enjoyed previously, another developed improved links with her family. The effects continued into the next six months with one patient organising to move house to a more central location in town. Each felt that they were more prepared to cope in the normal day-to-day activities they had wanted to enjoy prior to the sessions. As a group they identified the acupuncture as an important factor in their new attitude.
While this case study has obvious flaws in terms of sample size, outcome measures and no control group, this offers an objective, standardised, repeatable treatment that (in this case) offers hope of relief in a small but resource intensive group. These individuals do not occupy the “sexy” areas of self-harm, suicide, schizophrenia and so on, but are sad, lonely and anxious to the degree that their lives lose meaning and direction. The grandmother waiting for a phone call, the widow with no need to get out of bed in the morning and the wife who just doesn’t know what to do with herself.
As the population of chronic non-responding patients is small, and occupy a group likely to have variable attendance, it would require a multi-centre trial to ensure that any research performed would have the power and validity to make a definitive conclusion. Please contact the author if you would be interested in taking this further.
Competing interests None declared.
Provenance and peer review Not commissioned; not externally peer reviewed.
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