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The role of Kampo (Japanese traditional herbal) medicine in psychosomatic medicine practice in Japan
International Congress Series 1287 (2006) 304 – 308
www.ics-elsevier.com
The role of Kampo (Japanese traditional herbal) medicine in psychosomatic medicine practice in Japan Takakazu Oka * Department of Neurology, Division of Shinryonaika (Psychosomatic Medicine), University of Occupational and Environmental Health, Iseigaoka 1-1, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
Abstract. In Japan, herbal medicine called Kampo plays an important role in healthcare. More than 70% of physicians prescribe Kampo medicines for their patients as well as modern medicines. Some physicians prescribe Kampo medicine to compensate for the shortcomings of modern medicine. Other physicians prescribe several Kampo medicines as first-line drug therapy because double-blind, randomized, controlled studies have demonstrated their usefulness. Recent basic research has revealed that Kampo has multiple sites of action to restore homeostasis in highly stressed patients. It has been demonstrated that a single Kampo formula acts on both the central nervous system and peripheral target organs, i.e., the mind and body, to improve stress-induced conditions. Therefore, today, many Japanese psychosomatic physicians combine conventional psychosomatic therapies and Kampo to treat stress-related diseases. This integrated approach is now called Kampo psychosomatic medicine. D 2005 Elsevier B.V. All rights reserved. Keywords: Kampo; Stress; Alternative medicine; Psychosomatic diseases; Functional dyspepsia
1. Introduction In Japan, herbal medicine called Kampo is one of the most popular alternative therapies. In fact, many physicians specializing in psychosomatic medicine prescribe Kampo (herbal medicines) as well as modern drugs. According to the Nikkei Medical survey conducted in 1998, more than 70% of physicians prescribe Kampo medicines for their patients. In this article, I would like to present an overview of how * Tel.: +81 93 603 1611; fax: +81 93 693 9842. E-mail address: [email protected]. 0531-5131/ D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2005.09.179
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psychosomatic physicians integrate Kampo and modern medicine in their clinical practice in Japan. 2. How unique is Kampo? Kampo is herbal medicine, but it is not like prescribing St. John’s wort for depression for several reasons. (1) A Kampo formulation consists of multiple raw herbs and the ratio of each herb in the formula is strictly fixed. (2) Kampo medicine is prescribed on the basis of sho, the Kampo diagnosis, and is not based on modern medical diagnosis. (3) Kampo is prescribed by medical doctors who have had training in modern medicine; this is completely different from China and Korea, where oriental medicine doctors only prescribe traditional herbal medicines. 3. Why do so many physicians prescribe Kampo? Why do so many modern-medicine physicians prescribe Kampo in Japan? There are several reasons. Firstly, patients ask for Kampo, which is alternative medicine. However, for Japanese people Kampo is traditional medicine as well. Therefore, not uncommonly, Japanese women with menopausal syndrome ask their doctors about the merits and potential problems of hormone replacement therapy and Kampo, and then, choose Kampo therapy. Secondly, National Health Insurance has approved 148 Kampo prescriptions for medical use. Thirdly, extract Kampo formulations are now available. Traditionally, to prepare for Kampo medicine patients had to decoct raw herbs in hot water every day. Japanese Kampo pharmaceutical companies now manufacture extracts of Kampo preparations to improve compliance. Soon after physicians began to prescribe extract Kampo medicines, Kampo became more widely accepted. Furthermore, extract preparations have several advantages including high standards of quality, uniformity, and safety. Therefore we were able to use extract preparations to conduct large-scale clinical studies. Double-blind, randomized, controlled studies using extract Kampo medicines have demonstrated the effectiveness of many Kampo medicines. Therefore some Japanese physicians prescribe Kampo medicines not as an alternative therapy but as first-line drug therapy. 4. Characteristics of Kampo medicine Most importantly, Japanese modern-medicine physicians prescribe Kampo because it has characteristics that compensate for the shortcomings of modern medicine [1,2]. (1) Kampo medicine places importance on subjective symptoms; therefore a therapeutic plan to treat patients can be formulated even if there are no abnormal findings to account for their physical symptoms. (2) In Kampo, the therapeutic focus is on restoring inner balance and enhancing recuperative power. This kind of therapy is very important when we treat stress-related symptoms in weak people, i.e., patients with chronic diseases, patients who have undergone chemotherapy or surgery, exhausted patients, or elderly patients. (3) Kampo considers mind and body as one. As each Kampo formula includes multiple raw herbs, one Kampo formulation usually has multiple sites of action. In patients suffering from stress-related psychosomatic disorders, a single Kampo medicine is demonstrated to act on both mind and body.
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T. Oka / International Congress Series 1287 (2006) 304–308
5. Ki (Qi): a key concept that connects mind and body In Kampo medicine, the concept of Ki plays a primary role in the assessment of clinical conditions. Ki is a vital energy that allows the mind and body to function appropriately, which may correspond to activities of the central nervous system (CNS) and autonomic nervous system. The functioning of Ki is disturbed by psychosocial stressors. One disorder of Ki is kikyo, a state of Ki deficiency. In this state, patients complain of physical symptoms such as easily become fatigue, or loss of appetite, and psychological symptoms such as loss of enthusiasm. If the patient exhibits kikyo with upper gastrointestinal (GI) tract symptoms, the Kampo formula called rikkunshito is widely prescribed. For example, a 24-year-old woman came to our hospital complaining of abdominal discomfort, nausea, and fatigue. These symptoms began 2 years after she obtained a job in a trading company. She worked very hard until late at night. However, she began to feel that it was hard for her to continue the job because there was too much pressure on her. When she felt strong pressure, her physical symptoms became worse and sometimes she lost confidence in her ability to perform her job and felt depressed. Blood test and endoscopic findings were normal. The psychiatrist may diagnose mild depression in this patient and the gastroenterologist may diagnose functional dyspepsia (FD). From the Kampo point of view, I would diagnose kikyo tendency, with kikyo (exactly, kikyo of spleen and stomach induced by stagnation of ki of liver) becoming evident because of psychosocial stressors. Her constitution was fragile. Even when she was healthy, she tired easily after physical education class and was frustrated by feeling coldness in the limbs, especially in airconditioned rooms in the summer. These characteristics suggest that she basically had kikyo tendency. Therefore, one of the strategies for treating her is to prescribe rikkunshito in order to minimize kikyo and enhance energy to cope with stressors. 6. Rikkunshito has multiple sites of action to restore homeostasis in stress-induced FD patients Rikkunshito sho patients, i.e., those whose conditions deserve treatment by rikkunshito, are almost the same as patients with dysmotility-like dyspepsia in modern medicine if their constitution is fragile. Therefore, I would like to explain how rikkunshito works on dysmotility-like dyspepsia. 6.1. CNS We administered rikkunshito for 4 weeks to 15 FD patients and observed the changes in depression-related subjective symptoms. Rikkunshito significantly decreased depression scores as assessed by Self-Rating Questionnaire for Depression. Rikkunshito especially improved fatigue, depressed mood, and appetite loss [3]. 6.2. The hypothalamic-pituitary-adrenocortical (HPA) axis We also observed the effect of rikkunshito on serum cortisol level at 9 o’clock in the morning in 23 FD patients. In patients whose serum cortisol levels were higher than the normal range (n = 7), 4 weeks of administration of rikkunshito significantly decreased cortisol levels. In contrast, two patients had cortisol levels below the normal range. In
T. Oka / International Congress Series 1287 (2006) 304–308
307
these patients, rikkunshito gradually increased the cortisol level to the normal range. For example, in one patient, serum cortisol level before treatment was 3.8 Ag/dl (normal range, 5–15 Ag/dl). It increased to 5.0 Ag/dl and 10.7 Ag/dl at 4 weeks and 16 weeks, respectively, after administration of rikkunshito [4]. Therefore rikkunshito is suggested to have a modulatory effect on the HPA axis in FD patients. Another study demonstrated that rikkunshito attenuates acute stress-induced increase in serum cortisol level in healthy subjects [5]. 6.3. Upper GI tract symptoms One double-blind, randomized, controlled study has demonstrated that rikkunshito improves abdominal discomfort in FD patients [6]. Another study demonstrated that rikkunshito is more effective than the prokinetic drug, cisapride [7]. 6.4. Gastric motility In FD patients, gastric motility such as gastric adaptive relaxation and gastric emptying are impaired and the motility dysfunction is assumed as one of the causes of upper GI tract symptoms. Animal and human studies have demonstrated that rikkunshito promotes gastric adaptive relaxation and accelerates gastric emptying [8–10]. One study showed that rikkunshito improves the delayed GI tract motility induced by high temperature and humidity stress [11]. 6.5. Nonspecific complaints and quality of life Rikkunshito is demonstrated to improve nonspecific symptoms in FD patients such as fatigue, coldness of limbs, and orthostatic dizziness [7,12].
Fig. 1. Mind/body effects of rikkunshito on stress-induced FD patients. Rikkunshito has anti-ulcer effects, too.
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T. Oka / International Congress Series 1287 (2006) 304–308
To summarize, studies have demonstrated that rikkunshito has multiple sites of action to restore homeostasis in stress-induced FD patients (Fig. 1). Harasawa et al. demonstrated that rikkunshito is more effective in females whose ages are 40–49 and 60–69, and whose vital energy or physical strength has decreased [6]. This suggests that rikkunshito is more effective when it is prescribed according to sho, traditional diagnosis, than the modern medical diagnosis of FD. 7. Emerging Kampo psychosomatic medicine Recent basic research revealed that, like rikkunshito, Kampo formulas used for psychosomatic diseases act on both the CNS and peripheral target organs, i.e., the mind and body, improving stress-induced conditions. This is the most important reason why psychosomatic physicians prescribe Kampo medicine for highly stressed patients. Some physicians prescribe Kampo in combination with modern medicines to compensate for the shortcomings of modern drug therapies. Other physicians prescribe several Kampo medicines as first-line drug therapy. Such formulas include rikkunshito for functional dyspepsia and keishikasyakuyakuto for irritable bowel syndrome. In 1982, psychosomatic medicine specialists and Kampo specialists gathered and founded the Japanese Association of Oriental Psychosomatic Medicine, and they have been striving to integrate Kampo and psychosomatic medicine. Today, most Japanese psychosomatic physicians combine conventional psychosomatic therapies, including psychotherapy and relaxation training, and Kampo to treat stress-related diseases. This combined approach is now called the Kampo psychosomatic approach. Yasuo Otsuka, a famous Kampo expert, said that if one modern-medicine expert and one Kampo expert see the same patient separately, it is not necessarily the best for the patient. He stressed the importance of training ourselves so that we can utilize both medicines. This is also the case in psychosomatic medicine. If one expert psychiatrist and one internal medicine specialist see the same patient separately, it may not be the best for the patient who complains of physical symptoms due to stress. This is the reason why psychosomatic internists exist and Kampo psychosomatic medicine has emerged in Japan. When we treat the patient, we have to consider what is best for the patient and listen to how the patient wants to be treated. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]
T. Oka, Kampo Med. 55 (2004) 53 – 58. T. Oka, J. Jpn. Assoc. Oriental Psychosom. Med. 19 (2004) 12 – 19. T. Oka, et al., Rinsho to Kenkyu 67 (1990) 243 – 245. T. Oka, et al., Jpn. J. Oriental Med. 43 (1993) 439 – 446. T. Naito, et al., Biol. Pharm. Bull. 26 (2003) 101 – 104. S. Harasawa, et al., Igaku no Ayumi 187 (1998) 207 – 229. A. Miyoshi, et al., Prog. Med. 11 (1991) 1605 – 1631. T. Hayakawa, et al., Drugs Exp. Clin. Res. 25 (1999) 211 – 218. S. Harasawa, et al., Shokakika 12 (1990) 215 – 222. T. Kido, et al., J. Pharmacol. Sci. 98 (2005) 161 – 167. M. Tomokane, et al., Methods Kampo Pharmacol. 1 (1997) 110 – 116. S. Harasawa, et al., Prpg. Med. 19 (1999) 843 – 848.
www.ics-elsevier.com
The role of Kampo (Japanese traditional herbal) medicine in psychosomatic medicine practice in Japan Takakazu Oka * Department of Neurology, Division of Shinryonaika (Psychosomatic Medicine), University of Occupational and Environmental Health, Iseigaoka 1-1, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
Abstract. In Japan, herbal medicine called Kampo plays an important role in healthcare. More than 70% of physicians prescribe Kampo medicines for their patients as well as modern medicines. Some physicians prescribe Kampo medicine to compensate for the shortcomings of modern medicine. Other physicians prescribe several Kampo medicines as first-line drug therapy because double-blind, randomized, controlled studies have demonstrated their usefulness. Recent basic research has revealed that Kampo has multiple sites of action to restore homeostasis in highly stressed patients. It has been demonstrated that a single Kampo formula acts on both the central nervous system and peripheral target organs, i.e., the mind and body, to improve stress-induced conditions. Therefore, today, many Japanese psychosomatic physicians combine conventional psychosomatic therapies and Kampo to treat stress-related diseases. This integrated approach is now called Kampo psychosomatic medicine. D 2005 Elsevier B.V. All rights reserved. Keywords: Kampo; Stress; Alternative medicine; Psychosomatic diseases; Functional dyspepsia
1. Introduction In Japan, herbal medicine called Kampo is one of the most popular alternative therapies. In fact, many physicians specializing in psychosomatic medicine prescribe Kampo (herbal medicines) as well as modern drugs. According to the Nikkei Medical survey conducted in 1998, more than 70% of physicians prescribe Kampo medicines for their patients. In this article, I would like to present an overview of how * Tel.: +81 93 603 1611; fax: +81 93 693 9842. E-mail address: [email protected]. 0531-5131/ D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2005.09.179
T. Oka / International Congress Series 1287 (2006) 304–308
305
psychosomatic physicians integrate Kampo and modern medicine in their clinical practice in Japan. 2. How unique is Kampo? Kampo is herbal medicine, but it is not like prescribing St. John’s wort for depression for several reasons. (1) A Kampo formulation consists of multiple raw herbs and the ratio of each herb in the formula is strictly fixed. (2) Kampo medicine is prescribed on the basis of sho, the Kampo diagnosis, and is not based on modern medical diagnosis. (3) Kampo is prescribed by medical doctors who have had training in modern medicine; this is completely different from China and Korea, where oriental medicine doctors only prescribe traditional herbal medicines. 3. Why do so many physicians prescribe Kampo? Why do so many modern-medicine physicians prescribe Kampo in Japan? There are several reasons. Firstly, patients ask for Kampo, which is alternative medicine. However, for Japanese people Kampo is traditional medicine as well. Therefore, not uncommonly, Japanese women with menopausal syndrome ask their doctors about the merits and potential problems of hormone replacement therapy and Kampo, and then, choose Kampo therapy. Secondly, National Health Insurance has approved 148 Kampo prescriptions for medical use. Thirdly, extract Kampo formulations are now available. Traditionally, to prepare for Kampo medicine patients had to decoct raw herbs in hot water every day. Japanese Kampo pharmaceutical companies now manufacture extracts of Kampo preparations to improve compliance. Soon after physicians began to prescribe extract Kampo medicines, Kampo became more widely accepted. Furthermore, extract preparations have several advantages including high standards of quality, uniformity, and safety. Therefore we were able to use extract preparations to conduct large-scale clinical studies. Double-blind, randomized, controlled studies using extract Kampo medicines have demonstrated the effectiveness of many Kampo medicines. Therefore some Japanese physicians prescribe Kampo medicines not as an alternative therapy but as first-line drug therapy. 4. Characteristics of Kampo medicine Most importantly, Japanese modern-medicine physicians prescribe Kampo because it has characteristics that compensate for the shortcomings of modern medicine [1,2]. (1) Kampo medicine places importance on subjective symptoms; therefore a therapeutic plan to treat patients can be formulated even if there are no abnormal findings to account for their physical symptoms. (2) In Kampo, the therapeutic focus is on restoring inner balance and enhancing recuperative power. This kind of therapy is very important when we treat stress-related symptoms in weak people, i.e., patients with chronic diseases, patients who have undergone chemotherapy or surgery, exhausted patients, or elderly patients. (3) Kampo considers mind and body as one. As each Kampo formula includes multiple raw herbs, one Kampo formulation usually has multiple sites of action. In patients suffering from stress-related psychosomatic disorders, a single Kampo medicine is demonstrated to act on both mind and body.
306
T. Oka / International Congress Series 1287 (2006) 304–308
5. Ki (Qi): a key concept that connects mind and body In Kampo medicine, the concept of Ki plays a primary role in the assessment of clinical conditions. Ki is a vital energy that allows the mind and body to function appropriately, which may correspond to activities of the central nervous system (CNS) and autonomic nervous system. The functioning of Ki is disturbed by psychosocial stressors. One disorder of Ki is kikyo, a state of Ki deficiency. In this state, patients complain of physical symptoms such as easily become fatigue, or loss of appetite, and psychological symptoms such as loss of enthusiasm. If the patient exhibits kikyo with upper gastrointestinal (GI) tract symptoms, the Kampo formula called rikkunshito is widely prescribed. For example, a 24-year-old woman came to our hospital complaining of abdominal discomfort, nausea, and fatigue. These symptoms began 2 years after she obtained a job in a trading company. She worked very hard until late at night. However, she began to feel that it was hard for her to continue the job because there was too much pressure on her. When she felt strong pressure, her physical symptoms became worse and sometimes she lost confidence in her ability to perform her job and felt depressed. Blood test and endoscopic findings were normal. The psychiatrist may diagnose mild depression in this patient and the gastroenterologist may diagnose functional dyspepsia (FD). From the Kampo point of view, I would diagnose kikyo tendency, with kikyo (exactly, kikyo of spleen and stomach induced by stagnation of ki of liver) becoming evident because of psychosocial stressors. Her constitution was fragile. Even when she was healthy, she tired easily after physical education class and was frustrated by feeling coldness in the limbs, especially in airconditioned rooms in the summer. These characteristics suggest that she basically had kikyo tendency. Therefore, one of the strategies for treating her is to prescribe rikkunshito in order to minimize kikyo and enhance energy to cope with stressors. 6. Rikkunshito has multiple sites of action to restore homeostasis in stress-induced FD patients Rikkunshito sho patients, i.e., those whose conditions deserve treatment by rikkunshito, are almost the same as patients with dysmotility-like dyspepsia in modern medicine if their constitution is fragile. Therefore, I would like to explain how rikkunshito works on dysmotility-like dyspepsia. 6.1. CNS We administered rikkunshito for 4 weeks to 15 FD patients and observed the changes in depression-related subjective symptoms. Rikkunshito significantly decreased depression scores as assessed by Self-Rating Questionnaire for Depression. Rikkunshito especially improved fatigue, depressed mood, and appetite loss [3]. 6.2. The hypothalamic-pituitary-adrenocortical (HPA) axis We also observed the effect of rikkunshito on serum cortisol level at 9 o’clock in the morning in 23 FD patients. In patients whose serum cortisol levels were higher than the normal range (n = 7), 4 weeks of administration of rikkunshito significantly decreased cortisol levels. In contrast, two patients had cortisol levels below the normal range. In
T. Oka / International Congress Series 1287 (2006) 304–308
307
these patients, rikkunshito gradually increased the cortisol level to the normal range. For example, in one patient, serum cortisol level before treatment was 3.8 Ag/dl (normal range, 5–15 Ag/dl). It increased to 5.0 Ag/dl and 10.7 Ag/dl at 4 weeks and 16 weeks, respectively, after administration of rikkunshito [4]. Therefore rikkunshito is suggested to have a modulatory effect on the HPA axis in FD patients. Another study demonstrated that rikkunshito attenuates acute stress-induced increase in serum cortisol level in healthy subjects [5]. 6.3. Upper GI tract symptoms One double-blind, randomized, controlled study has demonstrated that rikkunshito improves abdominal discomfort in FD patients [6]. Another study demonstrated that rikkunshito is more effective than the prokinetic drug, cisapride [7]. 6.4. Gastric motility In FD patients, gastric motility such as gastric adaptive relaxation and gastric emptying are impaired and the motility dysfunction is assumed as one of the causes of upper GI tract symptoms. Animal and human studies have demonstrated that rikkunshito promotes gastric adaptive relaxation and accelerates gastric emptying [8–10]. One study showed that rikkunshito improves the delayed GI tract motility induced by high temperature and humidity stress [11]. 6.5. Nonspecific complaints and quality of life Rikkunshito is demonstrated to improve nonspecific symptoms in FD patients such as fatigue, coldness of limbs, and orthostatic dizziness [7,12].
Fig. 1. Mind/body effects of rikkunshito on stress-induced FD patients. Rikkunshito has anti-ulcer effects, too.
308
T. Oka / International Congress Series 1287 (2006) 304–308
To summarize, studies have demonstrated that rikkunshito has multiple sites of action to restore homeostasis in stress-induced FD patients (Fig. 1). Harasawa et al. demonstrated that rikkunshito is more effective in females whose ages are 40–49 and 60–69, and whose vital energy or physical strength has decreased [6]. This suggests that rikkunshito is more effective when it is prescribed according to sho, traditional diagnosis, than the modern medical diagnosis of FD. 7. Emerging Kampo psychosomatic medicine Recent basic research revealed that, like rikkunshito, Kampo formulas used for psychosomatic diseases act on both the CNS and peripheral target organs, i.e., the mind and body, improving stress-induced conditions. This is the most important reason why psychosomatic physicians prescribe Kampo medicine for highly stressed patients. Some physicians prescribe Kampo in combination with modern medicines to compensate for the shortcomings of modern drug therapies. Other physicians prescribe several Kampo medicines as first-line drug therapy. Such formulas include rikkunshito for functional dyspepsia and keishikasyakuyakuto for irritable bowel syndrome. In 1982, psychosomatic medicine specialists and Kampo specialists gathered and founded the Japanese Association of Oriental Psychosomatic Medicine, and they have been striving to integrate Kampo and psychosomatic medicine. Today, most Japanese psychosomatic physicians combine conventional psychosomatic therapies, including psychotherapy and relaxation training, and Kampo to treat stress-related diseases. This combined approach is now called the Kampo psychosomatic approach. Yasuo Otsuka, a famous Kampo expert, said that if one modern-medicine expert and one Kampo expert see the same patient separately, it is not necessarily the best for the patient. He stressed the importance of training ourselves so that we can utilize both medicines. This is also the case in psychosomatic medicine. If one expert psychiatrist and one internal medicine specialist see the same patient separately, it may not be the best for the patient who complains of physical symptoms due to stress. This is the reason why psychosomatic internists exist and Kampo psychosomatic medicine has emerged in Japan. When we treat the patient, we have to consider what is best for the patient and listen to how the patient wants to be treated. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]
T. Oka, Kampo Med. 55 (2004) 53 – 58. T. Oka, J. Jpn. Assoc. Oriental Psychosom. Med. 19 (2004) 12 – 19. T. Oka, et al., Rinsho to Kenkyu 67 (1990) 243 – 245. T. Oka, et al., Jpn. J. Oriental Med. 43 (1993) 439 – 446. T. Naito, et al., Biol. Pharm. Bull. 26 (2003) 101 – 104. S. Harasawa, et al., Igaku no Ayumi 187 (1998) 207 – 229. A. Miyoshi, et al., Prog. Med. 11 (1991) 1605 – 1631. T. Hayakawa, et al., Drugs Exp. Clin. Res. 25 (1999) 211 – 218. S. Harasawa, et al., Shokakika 12 (1990) 215 – 222. T. Kido, et al., J. Pharmacol. Sci. 98 (2005) 161 – 167. M. Tomokane, et al., Methods Kampo Pharmacol. 1 (1997) 110 – 116. S. Harasawa, et al., Prpg. Med. 19 (1999) 843 – 848.