Abstract
Background
Acupuncture, an ancient therapeutic technique, is emerging as an important modality of complementary medicine in the treatment of psychological diseases. If one protocol existed for treatment of depression with acupuncture regardless of their Chinese Medical diagnosis, it would certainly accelerate researches and incorporation of acupuncture into conventional medicine. In this article all the patients were diagnosed by DSM 4 and were in the range of moderate to severe. The treatment of acupuncture had been performed by one protocol for all of them.

Objective
To describe the outcome of patients with major depressive disorder diagnosis with moderate and severe types that received acupuncture treatment.
Design, Setting and Patients
Case series of 60 patients that used acupuncture for treatment of Major Depressive Disorder of moderate to severe; that their diagnosis made by using criteria of DSM 4. The treatment and follow up performed from Mar/2006 to Jan/2008.

Intervention
10 treatment sessions: every other day for 5 treatments, every week for 3 treatments and every other week for 2 treatments. Treatment consisted of nearly 20 acupuncture points, based on one formula for all of them. Needles placed bilaterally and De Qi was obtained.

Main outcome measure
Principally improvement of depressive symptoms and underwent Hamilton Depressive Scale in the beginning and in the end of the course. For those that considered being in full remission should have improvement of 7 or more in HDSD and at least two months without symptoms.

Results
7 patients did not complete the course and 53 of them completed the treatment (88.3%). 5 of them did not respond and the rest of them were in full remission based on the DSM 4 (80%).

Conclusion
Acupuncture is an effective modality in the treatment of moderate to severe depression, regardless of duration of disease.

Key Words
DSM 4, Hamilton Depressive Scale for Depression, Zang-fu organs, and liver yang.

Introduction
Although, undergoing TCM diagnosis procedure is essential in the treatment of patients when choosing acupuncture treatment for them. But it seems that in-patients with the conventional medicine diagnosis of depression of moderate to severe threshold because the derangement due to consumption of liver yin by hyperactivity of liver yang or liver Qi stagnation, is not merely one organ system involvement, in the treatment all organ system should be targeted unless treatment would not be successful. All the symptoms in the depression with the magnitude of moderate to severe can be explained by TCM as derangement of several Zang-Fu organs. Therefore, treatment approach should be regulation of Qi in every of them. For this reason in the protocol of treatment every of them are targeted and the diagnosis based on TCM can be omitted. Although, the diagnosis process in TCM by using pulse and tongue diagnosis and history taking can make diagnosis of depression without need to use any other means. But in order to accelerate incorporation of acupuncture into main stream medicine and even in acupuncture treated group with the use of one protocol leads to near to similar effect; existence of one treatment protocol for the disease like depression is a necessary objective.

Here some data about prevalence of depression today and in future.

Research suggests that 1 in 4 people will experience some kind of mental health problem in the course of a year. (Bird, 1999). A 1993 study estimated that depression alone costs 3 billions pounds each year in England when lost productivity and the cost of welfare benefits are taken into account, with direct cost to the National Health Service estimated at 420 million pound per year (Kind and Sorenson, 1993). While conventional treatments like psychotherapy and medication alleviate the blues in a whopping 50% to 70% of patients who complete the regimen, about one-third of those who begin therapy never complete it because they see no improvement or experience debilitating side effects. Even among people who do recover from depression, more than one-third relapses within 18 months. (Psychology Today, Sep, 1999 by C.C.)
Several facts exist today; first its' current high incident, another one is expectation of increase of it in future; the last one is unsatisfactory result from existing drug therapy. Another effective approach is highly necessary and when this effective approach does not have any important side effect and has been used for several centuries' looks lucrative. But the researchers and clinicians do not have one protocol that can lead to a similar result in one group of depressed patients. It seems that when the treatment given by one protocol can effectively hinder the existence problem in incorporation of acupuncture in the treatment of depression. The clinician and researcher expect to see similar result in similar intervention.

From the 60 aforementioned patients brief history of five of them will be presented. All of the patients that have been treated got inform consent in the beginning of therapy and agreed to be participated in series report without directly mentioning their personnel information.

Case number 1:
This patient was 41, male, married and had three children at the time for interview. His symptoms were worthlessness, anhedonia, insomnia, severe agitation, fears, total loss of functioning and besides them feeling of guiltiness. He was agitated, responded to the questions with delay and in questioning had libido. And he was very suspicious, lost 5 kg of weight and did not accept that had depression.
He had an interview with psychiatrist and was referred him for hospitalization but he did not accept. And after a short period of drug treatment discontinued them because of side effects.
His diagnosis based on DSM four was Major Depressive Disorder, Single Episode, and Severe with melancholic features.
The date of first interview was 10/6/2007 and in the same day the treatment begun. Hamilton Rating Scale for Depression at the first interview was 32 and two months later after receiving ten sessions of acupuncture was 20. He was in full remission 2 months later and 6 months later.

Case number 2
The patient was 50, female, married with a chronic history of major depressive disorder. The date of first interview was 18/ Apr/2007. The past history consisted of near to 21 days of hospitalisation and 6 courses of electroconvulsive therapy twelve years ago, several attempted suicides. And she has been constantly with two or three antidepressant and antianxiety drug therapy. But as she said with full dosage of several of them, only her symptoms subsided mildly.
Her conventional medical diagnosis based on DSM four was; Major depressive Disorder, Chronic, severe without psychotic features with Hamilton Depressive Scale of 32 at the first day of interview. She was on the drug therapy by psychiatrist with combination of SSRI and Tricyclic Antidepressant and Antianxiety agent, in the time of first interview. The method of treatment for this patient because of chronically and depletion of kidney yin besides the protocol was consisting of KD 3 too.
She was in complete remission two months after beginning of therapy and six months later. ). Her Hamilton Depressive Scale two months later in 17/June was 22 following the therapy with acupuncture. In telephone conversation with her, she was satisfactory and has been without any drug therapy (in the date of 20/Feb/2008). She was complaining about her affect but she said that it did not require therapy and did not interfere with her life (mild remnant depression).

Case number 3
The patient was a male of 40 with over 15 years of depression, date of first interview and beginning of therapy was at 14/May/2007. He received several courses of drug therapies. But he lost his job in the beginning of disease and has been in cover of special welfare organization because of inability to work. His conventional medicine diagnosis that performed by several psychiatrists was; major depressive disorder, chronic, severe without psychotic features.
He resumed a new job one-month after beginning of therapy and in his follow up was in full remission. His HDSP in the first interview was 30 and dropped by 8 after two months of receiving the therapy.

Case number 4
This patient was 36, female, recently discharged from psychiatric hospital. And although, she was on the treatment for over one-month her depressive symptoms were not subsided. Her DSM diagnosis was MDD, Single Episode, and Severe without psychotic features.

After five sessions, she decided to discontinue the drug therapy because of side effects and her condition improved. Her first interview and HRSD was 26 and the date was at the 18/June/2007 and two months later it was 18. She remained in full remission six months later.

Case number 5
The patient was a female, married, and 32. Her depressive disorder was chronic with near to 10 years of duration. And she hospitalized for several times and the last time was in last year. In which she received 10 sessions of ECT. Until the date of first acupuncture session that was at the time of first interview, was under drug therapy.
The date of first interview was at the 5/Jul/2006 and in that time HRSD was 30. She was under drug treatment at the time of first interview. The treatment had been begun at the date of first interview and received 10 sessions of acupuncture treatment and her HRSD two months later decreased by 10 and was 20. In the follow up six months later, one year and last time at the 19/Feb, her condition was stable.

Methods
In this protocol all affected Zang-Fu organs is deliberately targeted in acupuncture treatment. The most frequently used points were; ST 36, ST 25, SP 6 for harmony of spleen and stomach; GB 34, LR 3 for dispersing the liver; Du 20, Sishenchon for soothing their minds and improve circulation of Qi in the whole body. And other points were CV 12 for strengthen yang meridian of stomach; CV 6 for strengthen of stomach and spleen and tonification of Qi; HT 7 for tonification of heart Qi; and the acupoint LI 4 because in accompany with LR3 improve the circulation of Qi and blood. In the chronic patients with depression because of Qi of kidney is also altered by the long standing disease and their pulses loss their root, therefore, in them KD 3 had been used.

Result
The male proportion in this series was 16 male (26.6%) and female proportion was 73.4%. Nine patients were in single episode (15%) of patients and 51 of them were chronic (85%). Twenty of them were moderate (33.3%) and the rest of them were severe (66.7%). Two of them were with congruent psychotic features (3.3%) and 16 patients were with atypical features (26.6%). 48 (80%) patients completed the courses and were in full remission (for at least two months without symptoms) and 5 of them were incompletely treated and 2 were not responded and 7 were not complete the courses (20%).

Discussion
It seems that use of acupuncture in this intractable disease with such lower rate of side effects and high rate of success could be justifiable. Although, for confirmation of it more research in the greater population, randomized and double blinded is necessary.
By incorporation of this method of treatment when eligible by the further research could revolutionize the treatment of major depression of moderate to severe in future. 
Even though, some randomized research performed especially more prominent one at University of Arizona and in Tucson. But the matter is that the patients with depression had mild to moderate type of depression. Those types more affected by society and by learning helplessness from society (as some psychologist described). Although, results in comparison with drug therapy are encouraging. But future researches should compare acupuncture treatment in those with moderate and severe types with other ways of therapy and using the proposed protocol in this article can be a milestone in this regard.

Another research that mainly focused on scientific documentation of effects of acupuncture on central nervous system that performed at Massachusetts general hospital, department of radiology. They stimulated a point that was LI4 and performing fMRI. They quoted "We hypothesize that modulation of subcortical structures may be an important mechanism by which acupuncture exerts its complex multisystem effects". Therefore, acupuncture effects on depression should be exert its' effects via central nervous system.
With through scientific researches may be the rate of compliance could be increase. In this series, the main reason for quitting of therapy (in seven patients 20% of cases) was lack of sufficient scientific resources about the affectivity of acupuncture on their disease. Even though, all of them got inform consent about treatment but it seems that they accept the acupuncture treatment as last resort and may be seeing similar treated patients, could be a motivation force for them. 

Because of the below fact the research upon effectiveness of acupuncture on depression should be in long duration.
Eighty to 90 percent of individuals will remit within 2 years of the first episode (Kapur & Mann, 1992). Thereafter, at least 50 percent of depressions will recur, and after three or more episodes the odds of recurrence within 3 years increases to 70 to 80 percent if the patient has not had preventive treatment (Thase & Sullivan, 1995). 

Conclusion
In this article only tried to represent a viable, acceptable way of treatment of this disease with acupuncture and for so many questions that remained, hope that further researches can answer them. But when in some cases in this study several hospitalisation and even in some electroconvulsive sessions were not successful and several acupuncture sessions can lead to better outcome, the scientific community in this field of medicine should begin their study and confirmation of it with haste. Another significant matter in treatment group is even though, their depression based on criteria of DSM4 treated but some remnant depressive mood remained. It can be concluded that for treatment of reservoir depression and gaining full recovery working statue, it should be complemented with other treatment options like psychotherapy. Even it may be better to treat mild depression with the mixture of acupuncture and psychotherapy. Even though, the result was encouraging but without further research it can not corollary related. 

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