A Survey of the Clinical Practice Status of Korean Medicine Doctors for Depression: Preliminary Data on Clinical Practice Guidelines

Article information

J Korean Med. 2024;45(4):1-17

Publication date (electronic) : 2024 December 1

doi : https://doi.org/10.13048/jkm.24053

Jin-Woo Suh¹, Sang-Ho Kim^2,

¹Department of Neuropsychiatry of Korean Medicine, 26338, Sangji University Korean Medicine Hospital, Sangji University, Wonju, Republic of Korea

²Department of Neuropsychiatry of Korean Medicine, 37685, Pohang Daegu Haany University Korean Medicine Hospital, Daegu Haany University, Pohang, Republic of Korea

Correspondence to: Sang-Ho Kim, Department of Neuropsychiatry of Korean Medicine, 37685, Pohang Daegu Haany University Korean Medicine Hospital, Daegu Haany University, Pohang, Republic of Korea, E-mail: omed22@naver.com

Received 2023 December 23; Revised 2024 June 29; Accepted 2024 November 12.

Abstract

Introduction

Depression is a prevalent and severe mental disorder characterized by persistent feelings of sadness and hopelessness, and loss of interest in once-enjoyed activities.¹⁾ It also manifests as emotional issues, changes in appetite or weight, sleep disturbances, fatigue or loss of energy, psychomotor agitation or retardation, difficulty in concentrating, feelings of worthlessness or guilt, and suicidal thoughts.¹⁾ According to the World Health Organization (WHO), the number of reported depression cases increased by 50% between 1990 and 2017, with over 264 million people affected worldwide.²⁾

The primary treatment options for depression include drug therapies such as antidepressants, non-pharmacological therapy, and cognitive behavioral therapy.³⁾ Although antidepressants are the most commonly used treatment for depression, several limitations exist, such as the variety of side effects and treatment-resistant depression.^4,5) Additionally, the administration of antidepressant medication to children and adolescents may be associated with suicidal ideation and attempts.⁶⁾ While cognitive behavioral therapy is an effective approach to treating depression, its utilization is impeded by high costs, a scarcity of skilled practitioners, and limited accessibility.⁷⁾ Consequently, there is a high interest in complementary and integrative medicine, such as herbal medicine, acupuncture, and mind-body interventions, to explore effective alternative treatments with fewer side effects that supplement the limitations of existing depression treatments.⁸⁾ Complementary and integrative medicine has been shown to be effective in treating depressive symptoms. Acupuncture, which helps treat depression, and meditation, qigong, and other psychotherapies have been suggested as helpful treatment techniques in clinical practice guidelines (CPGs) in many countries.^9,10)

Korean medicine (KM) is one of the dual axes of the national medical system in South Korea, along with conventional Western medicine.¹¹⁾ KM doctors (KMDs) employ a range of therapeutic modalities such as herbal medicines, acupuncture, moxibustion, cupping, and manual therapies in the clinical setting to manage diseases and conditions.¹²⁾ Based on the accumulated safety and efficacy evidence^13,14), KM has worked to develop appropriate standard of treatment methods and effective guidelines to gain government support.

Although the Korea Institute of Oriental Medicine developed a CPG for the treatment of depression in 2016¹⁵⁾, there is no survey regarding current practice status of KMDs for depression. Therefore, this survey aimed to document and analyze current practice status of KMDs who provided treatment for depression.

Materials and Methods

Results

1. Sociodemographic Characteristics

A total of 716 KMDs participated in the questionnaire, and data from four individuals who did not agree to provide their personal information were excluded. The distribution of the participating KMDs’ ages and working institutions are shown in Table 1. Among the participants, 66.43% were male and 33.57% were female.

Table 1

General demographic characteristics of the respondents

Meanwhile, 20.22% had less than 5 years of experience, 25.28% had 5–10 years, 32.44% had 10–20 years, 16.99% had 20–30 years, 55.34% were general practitioners, 11.94% had completed their specialist training or were currently interns, and 32.72% were specialists in KM, 4.21% were KM specialists in neuropsychiatry (Table 1).

2. Diagnostic Methods of Patients with Depressive Disorder

The number of depression diagnosis cases visiting the KM clinic per month was 1–5 in 62.50%. Furthermore, the number of cases of accompanying depression symptoms visiting KM clinics per month was 1–5 in 55.34% (Table 2).

Table 2

Number of patients diagnosed with depressive disorder or accompanying depression symptoms (during average 1 month)

The frequently used diagnostic tools were: patient’s self-report (54.35%), information through consultation (32.58%), assessment questionnaire (e.g., Beck’s Depression Inventory, Patient Health Questionnaire-9, Hamilton Depression Rating Scale) (7.58%), Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) or International Classification of Diseases-10 (ICD-10) (4.92%), Structured Clinical Interview for DSM-5 (SCID) (0.42%), and others (0.14%) (Table 3).

Table 3

Diagnostic tools for patients with depressive disorder

The KMDs’ common diagnosis codes for patients with depression in the KCD were as follows: Hwabyung (57.72%), liver qi stagnation pattern (56.74%), and depressive syndrome (43.12%) (Supplementary Table 1). The most common KM pattern identification for depressive disorder was pattern identification of Zang-fu organs (64.89%), followed by pattern identification of qi, blood, and yin yang (35.39%).

Among the 462 KCDs who used pattern identification of Zang-fu organs, the priority usage included the liver qi stagnation pattern (372 KMDs, 80.52%), deficiency of the heart and spleen pattern (32 KMDs, 6.93%). The second priority usage included the Qi stagnation transformed fire pattern (118 KMDs, 25.54%), deficiency of the heart and spleen pattern (110 KMDs, 23.81%).

4. Treatment of Patients with Depression

1) Motivation for Seeking KM Treatment in Patients with Depression

The main reasons why patients with depression seek KM treatment were as follows: “improvement of depression-related physical symptoms (81.46%),” “improvement of depression-related psychological symptoms (50.28%),” “abort or decrease dosage of psychiatric medication (37.22%),” “mitigating adverse effects of Western psychiatric medication (25.70%),” “not wanting Western psychiatric treatment (17.70%),” and others (0.84%).

2) Primary KM Treatment Methods for Patients with Depression

(1) Treatment methods

The most used treatment methods for depression among KMDs were acupuncture (86.94%) and herbal decoction (83.29%). Other treatments were utilized in the following order: Fifty-six National Health Insurance Service (NHIS) inclusion herbal extracts (44.10%), moxibustion (40.31%), NHIS exclusion herbal extracts (28.79%), electroacupuncture (24.72%), dry cupping (21.49%), wet cupping (20.37%), and phamacoacupuncture (19.80%) (Table 4).

Table 4

Primary Korean medicine treatment methods for patients with depression (multiple responses)

Among those who reported using KM psychotherapy, the following methods were frequently employed: relaxation by breath (62.65%), meditation (46.99%), supportive psychotherapy (33.73%), and emotional freedom techniques (EFT) (27.71%). The rate of use of the treatment methods was as follows: acupuncture (40.93%), herbal decoctions (37.84%), 56 NHIS inclusion herbal extracts (15.61%), and NHIS exclusion herbal extracts (15.10%).

(2) Herbal treatment

The most frequently administered herbal prescriptions for patients with depression by KMDs were as follows: Jiawei-Xiaoyao San (gami-soyo san) decoction (63.90%), Guipi Tang (guibi-tang) (58.71%), Guipi-Wen dan Tang (guibi-ondam tang) (44.66%), Wendan Tang (ondam tang) (41.85%), Chaihu-jia-longgu-muli Tang (sihoga-yonggol-moryeo tang) (40.17%), and Chaihu-Shugan Tang (siho-sogan tang) (34.69%).

The most preferred herbs for the treatment of patients with depression by KMDs were as follows: Bupleuri Radix (79.07%), Cyperi Rhizoma (78.09%), Ziziphi Semen (64.75%), Poria (43.96%), Ostreae Testa (42.98%), and Os Draconis (40.73%) (Supplementary Table 2). The average daily KMDs’ preferred herbal medicine doses were 2.31 ± 0.50 (n=708, excluding four cases with more than 10 doses per day), and the average of the total herbal medicine prescription days was 34.06 ± 23.91.

The most frequently preferred herbal extracts for patients with depression were as follows: Jiawei Guipi Tang (gami-guibi tang) extracts (n=271, 38.06%), Chaihu Shugan San (siho-sogan san) extracts (n=255, 35.81%), Jiawei Wen dan Tang (gami-ondam tang) extracts (n=248, 34.83%), Tianwang Buxin Dan (cheonwang-bosim dan) extracts (n=227, 31.88%), and Xiao Chaihu Tang (so-siho tang) extracts (n=190, 26.69%),. The KMDs’ preferred formulations of herbal medicine were as follows: herbal decoction (n=519, 72.89%), Fifty-six NHIS inclusion herbal extracts (n=116, 16.29%), and NHIS exclusion herbal extracts (n=51, 7.16%).

(3) Acupuncture treatment

The most commonly used type of acupuncture for depression by KMDs was body acupuncture (76.40%), saam acupuncture (31.46%), O-Haeng Acupuncture (12.50%), and constitutional acupuncture (11.24%) (Table 5). The most preferred meridians for acupuncture treatment of patients with depression were as follows: heart meridian of hand-Shaoyin (53.09%), liver meridian of foot-Jueyin (45.51%), and pericardium meridian of hand-Jueyin (42.98%) (Supplementary Table 3). The most preferred acupoints for treatment were as follows: GV20 (n=469, 65.87%), HT7 (n=385, 54.07%), PC6 (n=380, 53.37%), LI4 (n=318, 44.66%), SP6 (n=276, 38.76%), ST36 (n=234, 32.87%), CV17 (n=202, 28.37%), and EX-HN1 (n=192, 26.97%). The preferred number of acupuncture treatment days per week was 2.35 ± 0.89 (n=699, 13 cases entering more than 7 times a week were excluded because it was assumed that the number corresponding to one month), and the average number of total acupuncture treatment days was 35.63 ± 33.88.

Table 5

Acupuncture treatment methods for depression by KMDs

3) Appropriate Duration of KM Treatment for Depression

The most common length of time until depression symptoms improved was two to three weeks (n=202, 28.37%), followed by more than four weeks (n=186, 26.12%), and one to two weeks (n=160, 22.47%). The average duration of treatment for patients with depression treated with KM was more than 8 weeks (n=316, 44.38%), followed by 4–8 weeks (n=261, 36.66%), and 2–4 weeks (n=113, 15.87%).

4) Evaluation and Influencing Factors of Treatment of Depression

The most preferred method for evaluating the effectiveness of depression treatment was patient self-assessment (53.51%), followed by getting information through consultation (29.63%). The most important factor in improving depressive symptoms was establishing a smooth rapport with the patient (44.24%), followed by herbal medicine treatment (37.08%). The primary obstacle in the treatment of depression was the duration of the patient’s symptoms (52.25%), followed by the severity of depression (50.00%) (Table 6).

Table 6

Obstacles to the treatment of depression (multiple responses)

5) Preference for Expert Referral for Depression Treatment

A total of 622 KMDs expressed willingness to consult medical treatment experts (Including both Western and Korean neuropsychiatry) when treating patients, while 90 KMDs did not. The most frequently cited reason for consultation was the need for “more professional psychiatric counseling” (n=427, 68.65%), followed by the desire for a “more accurate diagnosis” (n=68, 10.93%), “admission is needed” (n=54, 8.68%), and “did not respond to the additional KM treatment at this clinic” (n=43, 6.91%). The most common reason for no consultation was “the current treatment is sufficient” (n=26, 28.89%), followed by “changes in the medical staff could have a negative impact on care” (n=17, 18.89%), and “do not have adequate feedback on the treatment process when consulted” (n=15, 16.67%).

Discussion

Previous studies have analyzed KM depression treatments and clinical cases that are reflected in existing clinical practice guidelines, but this is the first study to investigate current practice status of KMDs who treat depression.

A pattern identification is the act of determining the nature of pathology by differentiating ‘symptoms’ from the disease manifested in the patient. A considerable number of KMDs (n=149) provided responses encompassing pattern identification of both Zang-fu organs as well as qi, blood, and yin yang, which accounted for approximately 59.12% of all pattern identifications involving qi, blood, and yin yang. The liver qi stagnation pattern, deficiency of the heart and spleen pattern, as well as qi stagnation transformed fire pattern were the main pattern identifications of Zang-fu organs. Symptoms associated with depression often exhibited pathological indications related to the liver, heart, and elements reminiscent of fire in KM.¹⁹⁾ This result is similar to the frequent pattern presented in the Chinese prescription study of depression, including the liver qi stagnation pattern, and deficiency of the heart and spleen pattern.²⁰⁾ However, the difference is that no pattern includes the symptoms of fire or fever to express that the patient feels feverish or has an actual fever, such as qi stagnation transformed fire. This supports the notion that the symptoms of depression in Korea are characterized by fire or fever.

The preferred diagnosis codes of most KMDs were U221 Depressive syndrome (KM), U222 Hwabyung, and U65.1 Pattern of liver qi depression rather than F codes (which denote psychiatric diseases) such as F32.0 Mild depressive episode, F32.9 Depressive episode, and unspecified. It is assumed that this was not because patients did not meet the diagnostic criteria for depression or KMDs could not diagnose depression, but because patients were reluctant to be diagnosed with an F code for fear of stigma and failure of obtaining private insurance.²¹⁾ Therefore, medical staff prefer Korean medical diagnostic U codes to F codes. This phenomenon has also been mentioned in another study.¹⁷⁾ Hwabyung may have been frequently diagnosed because symptoms similar to depression are presented as diagnostic criteria for Hwabyung with a clear cause event, and related physical symptoms often overlap with depression.²²⁾ In addition, being diagnosed with Hwabyung is more easily accepted by patients with depression in Korean culture.

More than half (51.3%) of the patients with depression visiting the KM clinic were taking antidepressants when calculated as a median. These patients expressed a greater desire to improve their physical symptoms, while their expectations for improvement in psychological symptoms were about half as high. There was a total of approximately 600 visits to reduce side effects or reduce the proportion of treatment received from Western medicine. This finding suggests a substantial demand to reduce the side effects of depression treatment in Western medicine^4,5) and highlights the preference of patients to seek such alternatives from KM clinics. Previous studies have also shown that 53.6% of patients with severe depression turn to complementary and alternative medicine for treatment,²³⁾ indicating a strong inclination among patients with depression for a “natural approach” rather than conventional Western medicine.²⁴⁾

Acupuncture and herbal medicine have emerged as the most employed treatments by KMDs to treat depression. Among the types of herbal medicine, decoctions were the most preferred, followed by “56 NHIS inclusion herbal extracts” and “NHIS exclusion herbal extracts.” The treatment mechanisms of herbal medicines used for depression include the modulation of neurotransmitters and affecting neurotropic factors.²⁵⁾ Hence, herbal medicines are expected to be used in various forms in the future.

Acupuncture was deemed the most effective treatment, with general body acupuncture being the most frequently utilized method. Preferred acupoints such as GV20 and HT7, known for their effectiveness in managing mental and emotional symptoms, were often employed for insomnia and depression.²⁶⁾ Electroacupuncture and phamacoacupuncture constituted approximately one-fifth of the total treatments. Moxibustion, utilized for warming and relaxing the body, was employed by 40.31% of KMDs in patients with depression. Wet and dry cupping, which aid in relaxation and pain reduction, were also frequently employed by KMDs to alleviate depression symptoms by promoting body relaxation and warmth.

Giungoroen therapy is a technique in which the patient is guided to recognize the severity of the disease via conversation, and based on this, the patient adapts to society and improves the mind to overcome the disease.²⁷⁾ EFT is a meridian-based psychological therapy that improves psychologic and psychosomatic symptoms by applying tapping stimulations at several meridian acupoints.²⁸⁾ Psychotherapy techniques, such as assurance, are used and have the effect of alleviating depression symptoms.²⁸⁾ In addition to meditation and relaxation using breathing techniques, which are representative CIM therapies, KMDs use these therapies as KM psychotherapy. These treatments correspond to pure psychotherapy among all treatments, indicating that certain KMDs use psychotherapy rather than treating depression centered on physical symptoms. This illustrates the extent to which KMDs utilize psychotherapy. Its lack of popularity may be because the NHIS only covers treatment fees for KM neuropsychiatrists related to counseling or psychotherapy and that psychotherapy is more time-consuming than treating physical symptoms.

Regarding herbal medicine treatments, the most preferred type was herbal decoction, and when combined with 56 NHIS inclusion herbal extracts and NHIS exclusion herbal extracts, herbal extracts accounted for over 30% of all treatments. However, it is important to note that the selection of herbal medicines in the survey did not necessarily reflect the actual usage by KMDs. This is because the utilization of herbal medicines by KMDs depends on the composition of herbal medicine formulas. These formulas often involve the addition or removal of various herbs; however, there are a few cases in which the preferred medicinal herbs are used alone. The commonly used Bupleuri Radix or Cyperi Rhizoma is included as a constituent of Jiawei Xiaoyao San (gami-soyo san) or Chaihu Shugan Tang (siho-sogan tang), and so on, which is mostly used for depression.^29,30) Of course, Bupleuri Radix and Cyperi Rhizoma themselves are also effective in relieving symptoms of depression through the effect of relieving stagnation.^31,32) Therefore, they are widely used in herbal medicine formulas for depression and accompanying symptoms in KM.^32–34) KM psychotherapy was less preferred among KMDs (8.94%), and the response was focused on breathing relaxation and meditation, which can be performed easily in the clinical setting.

Determining the exact meaning behind the preference survey for herbal extracts presents a challenging issue. It remains unclear whether the preference for extracts indicates their use as an adjunct to decoction prescriptions for depression or if the extracts were employed as standalone treatments. However, since the presented extract prescriptions were similar to those of herbal decoctions mainly used for the treatment of depression, it can be assumed that the extracts were used preferably as standalone treatments. The most preferred formulation of herbal medicine was herbal decoction, suggesting that many KMDs believe it to be more effective. A survey conducted in Korea in 2021 on the actual conditions of herbal medicines revealed that the primary reason for the prevalence of decoctions among formulations was their “fast effect.” Additionally, the “convenience to add or subtract (according to symptoms)” ranked as the second most important factor.³⁵⁾

Guipi Tang (Guibi tang) decoction and Jiawei-Xiaoyao San (gami-soyo san) were the most preferred decoctions. These two herbal medicines are recommended prescriptions in the CPGs for depression by KMDs.¹⁴⁾ Guipi Tang is known for its effectiveness in treating depression without significant adverse effects³⁶⁾ and its ability to alleviate symptoms of insomnia, which is a common manifestation of depression.²⁵⁾ The effectiveness of Jiawei-Xiaoyao San in treating depression has also been shown, compared to the control group using paroxetine.²⁹⁾

Among the diagnostic tools used, self-reporting by patients was the most employed method by KMDs, followed by the gathering of information via consultation and assessment questionnaires. This shows that reliable diagnostic tools such as the DSM, SCID, and ICD-10 are not currently being used properly among KMDs. Presumably, this may be because KMDs only focus on KM diagnosis for treatment. However, medical data can only be meaningful as standard data for the appropriate treatment and evaluation of depression and future research if diagnoses are accurate. Currently, most KMDs are general practitioners, and very few of them are KM neuropsychiatrists. As of 2021, out of a total of 26,788 KMDs, only 3,432 are specialists, and among these, only 206 are KM neuropsychiatrists.³⁵⁾ Therefore, KMDs’ knowledge of the diagnosis and evaluation of mental disorders may be insufficient. Accordingly, education on the use of diagnostic tools to help make an appropriate diagnosis should be provided, and CPGs can be an important tool for such education.

According to this survey, the severity of depression and duration of the symptoms, as well as family and social support around the patient, were identified as important factors influencing treatment. In Korea, patients with depression visiting clinics tend to primarily complain about physical symptoms associated with depression³⁷⁾ he survey results indicate that many patients visit KM clinics to address the physical symptoms of depression.

The survey revealed that a significant number of KMDs did not utilize CPGs, indicating a lower level of interest in these guidelines. Therefore, it is crucial to explore strategies for enhancing the effective utilization of CPGs. The finding that many participating KMDs did not use medical guidelines underscores the need for improvements in this regard.

Limitations

The limitations of this study are as follows. First, the number of respondents was small, and therefore, the representativeness was low. Second, the definition of patients with depression was not clear. Since the questionnaire targeted all patients with depressive symptoms, it is difficult to organize contents only belonging to depressive disorders. Third, a bias may exist due to the possibility that not all oriental medical doctors participated in the survey, but only those who were interested in depression or who had seen many patients with depressive symptoms.

Despite these limitations, this survey is meaningful because it is the first survey to examine KMDs’ overall perception and treatment status of patients with depression. The opinions of these oriental doctors will be of great help in revising the treatment guidelines for depression. To address the above limitations, a participatory study with a larger number of participants or an analysis using government health insurance registration data should be considered.^38,39)

Conclusions

This survey provides insights into the clinical practice landscape of KMDs in treating depression, covering areas such as diagnosis, patient characteristics, and preferred treatments, with prescriptions and formulations of commonly used herbal medicines, as well as acupuncture treatment methods. Although these results should be interpreted with caution because of the low response rate and the possibility of biased selection, they are expected to serve as a good reference for KMDs who treat depression and researchers who are revising CPGs. Further well-designed studies involving a larger number of participants should be conducted.

Data Availability Statement

The data used to support the findings of this study are included within the article and its supplementary material.

Supplementary materials

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