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Acupuncture Tops Sham for Easing PTSD in Combat Veterans
— Large treatment effect observed for clinical and biological measures of combat-related PTSD
Acupuncture outperformed "sham" needling in clinical and biological measures of combat-related post-traumatic stress disorder (PTSD) in veterans, a prospective randomized trial showed.
In the intention-to-treat analysis, there was a large treatment effect of verum acupuncture (Cohen d 1.17), a moderate effect of sham acupuncture (d 0.67), and a moderate between-group effect favoring verum acupuncture (d 0.63, P=0.005), reported Michael Hollifield, MD, of the Tibor Rubin VA Medical Center in Long Beach, California, and co-authors in JAMA Psychiatry.
The effect pattern was similar in the treatment-completed analysis between the group receiving verum acupuncture -- which means "true" or "real acupuncture according to a healing tradition and protocol," said Hollifield -- and the sham group.
"While [PTSD is] thought of as a mental illness, it's really not, in some sense. It's an environmentally caused, whole-body illness that affects the brain and other parts of the body," Hollifield told MedPage Today. "And that's why we believe acupuncture, as a somatic treatment, works, because trauma is stored deep in other body systems."
"It's not just a psychological process," he added, noting this is his opinion, but one with which many of his patients agree.
While previous studies of acupuncture in civilians and active military troops have demonstrated its effectiveness, Hollifield said his study, which used improved controls, was needed to "definitively" support acupuncture for PTSD. He noted that "acupuncture ought to be considered a potential first-line treatment for PTSD."
There was also a significant pretreatment to post-treatment reduction in fear-conditioned extinction, which was assessed by a fear-potentiated startle response -- a sudden blast of air paired with a certain image, such as a blue box -- in the group receiving verum acupuncture versus the sham group, and a significant correlation (r=0.31) between symptom reduction and fear extinction.
For this secondary outcome, the startle response was measured using eyeblink electromyography, Hollifield explained. After treatment with either sham or verum acupuncture, Hollifield and his co-authors looked to see how long it takes for that fear response to dissipate when the stimulus -- that blast of air -- no longer occurs with the image.
"And we found that acupuncture distinguished itself very nicely from the sham procedure, by people extinguishing that fear response more rapidly after treatment in the acupuncture group than in the sham group," he said.
For this two-arm, parallel-group, blinded single-center study, participants were recruited using flyers and emails from April 2018 to May 2022. The researchers included 85 male and eight female veterans ages 18 to 55 (mean age 39.2, 47.3% white, 18.3% Asian) with moderate to severe PTSD.
About one-third of veterans saw moderate combat, 30% saw moderate heavy combat, and 16% saw heavy combat.
Both groups received 1-hour sessions twice weekly and were given 15 weeks to complete as many as 24 sessions.
The study used the Clinician-Administered PTSD Scale-5 (CAPS-5), the "gold standard" for PTSD assessment, to measure symptom reduction by assessing symptom severity pre- and post-treatment. The CAPS-5 includes 20 items, rated from 0 to 4 (with 4 representing the most severe), which are then totaled into a single severity score.
As for safety, 64 adverse events occurred, seven of which were study related, and three were potentially related.
Three participants experienced anxiety during physiology testing; one had nocturnal panic attacks; one had increased suicidal ideation, which resolved; and one withdrew prior to randomization owing to increased symptoms. One participant withdrew for intervention-related symptoms. No participants withdrew as a result of suicidal or homicidal ideation.
A limitation of the study was that it was difficult to design a "truly blinded study" of acupuncture, Hollifield said. "People know what they're getting, and the acupuncturist knows what they're delivering."
With this study completed, next steps are to compare acupuncture with other evidence-based treatments and to conduct cost-effectiveness studies.
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