Patterns of Integrative Korean Medicine Practice for Anxiety Disorders: A Survey among Korean Medicine Doctors (KMDs) in Korea

Anxiety disorder is known as the most common disease among psychiatric disorders. However, many studies have not been conducted in the Korean medicine area. This study explores the current state of anxiety disorder treatments of Korean medicine through a survey research. The survey for Korean medicine doctors (KMDs) on Korean medicine (KM) diagnosis and treatments for anxiety disorder was conducted online from December 21, 2016, to December 29, 2016. The results were divided into two groups, KMDs and Korean medicine neuropsychiatric specialists (KMNPS), and comparatively analyzed. Self-evaluation and counseling were the most common in both diagnostic methods and evaluation of treatment effects, and KMNPS tended to make extensive use of objective indicators. There was no difference in the rate of psychiatric medication use among the patients between KMD and KMNPS. The main reason for patients wanting KM treatment was the tapering cessation of psychiatric medications. The most common treatments were acupuncture, herbal medicine, and moxibustion, in addition to dry cupping in KMD and psychotherapy in KMNPS. The most important factor for treatment was herbal medicine treatment, followed by rapport formation in KMD and patient's temperament in KMNPS. Opinions on various items were presented as treatment barriers, and KMNPS tended to think more importantly about the patient's family problems. For the items to be additionally trained in the future, KMD chose the diagnostic tools and KMNPS chose psychotherapies. This study is the first study to analyze the clinical patterns for anxiety disorder in KMDs. KMD and KMNPS showed similar patterns in the perception, diagnosis, and treatment of anxiety disorders, but KMNPS tended to use objective indicators and psychotherapy more actively. Further clinical studies for the development of clinical guidelines should be additionally required.


Introduction
Anxiety disorder is the most common disease among psychiatric disorders. According to the WHO report, the proportion of the global population with anxiety disorders in 2015 is estimated to be 3.6% [1], and the total estimated number of people living with anxiety disorders in the world is 264 million. is total for 2015 reflects a 14.9% increase since 2005 [2]. A systematic analysis showed that the pooled period prevalence was 6.7% (6.0-7.6%) from 122 surveys with a lifetime prevalence of 12.9% (11.3-14.7%) from 70 surveys [3]. It is also shown that the lifetime prevalence of anxiety disorders in Korea has been reported as 9.3% (male 6.7% and female 11.7%) with the annual prevalence rate at 5.7% (male 3.5% and female 7.5%). at is almost two times higher than depression, at lifetime prevalence of 5.4% (male 3.3% and female 7.2%), with an annual prevalence rate of 3.1% (male 1.8% and female 4.3%) according to the Epidemiological Survey of Mental Disorders. In addition, the lifetime prevalence of all mental illnesses decreased from 29.9% in 2001 to 26.6% in 2016, but the lifetime prevalence of "anxiety disorder" has increased to 6.9% in 2006, 8.7% in 2011, and 9.3% in 2016 [4]. However, the lifetime use rate of mental health services for patients with anxiety disorders is still low at 25.1% in 2011 and 27.3% in 2016 [5].
Korean medicine doctor (KMD) is a Korean medical practitioner who provides diagnosis, treatment, and prescription and necessary medical consultations to maintain the desired level of health [6]. A Korean medicine specialist is a person who is certificated in oriental medicine and has acquired professional qualifications through one year of internship with three years of residence training after 2000. Currently, specialists are trained in 8 subject areas (Internal Korean Medicine, Acupuncture and Moxibustion Medicine, KM Obstetrics and Gynecology, KM Pediatrics, KM Rehabilitation, KM Neuropsychiatry, Sasang Constitutional Medicine, KM Ophthalmology, Otolaryngology and Dermatology). KM specialists accounted for about 9.1% of all KM doctors by 2013 [7]. Training subjects of Korean medicine neuropsychiatry specialist (KMNPS) include psychophysiology, psychopathology, psychopharmacology, neurology with several other psychological-psychiatric theories and techniques, psychiatric examination, differential diagnosis, psychological testing, specialized KM therapies for neuropsychiatric disorders, and KM psychotherapies such as Qi-gong and meditation, Korean traditional psychological-psychiatric theories, personality theories, and techniques [8].
ere are many types of psychiatric illnesses situated in KM institutions that are mostly related to physical symptoms. KM, which has a symptom-based approach to determine the treatment through the identification of specific etiology or specific symptoms rather than prioritizing the name of the disease [9], may have an advantage in anxiety disorders, which indicate the diversity of symptoms among psychiatric disorders. In fact, complementary and alternative medicine treatments including KM and Chinese medicine are used worldwide [10]. However, the standard of care has not been established due to subjective diagnosis and various treatment methods. erefore, the pursuit of evidence-based care is a very important topic, and the demand for clinical practice guidelines (CPG) is increasing. In the Chinese version of the Evidence-Based Guidelines for Clinical Practice in Chinese Medicine, depressive disorders and insomnia CPG are mentioned, but none exists for anxiety disorders [11]. e purpose of this study is to analyze the KM treatment pattern of anxiety disorders and reflect the data in developing KM CPG for anxiety disorders. Also, the study is to investigate the possibility of clinical application of KM therapy tools based on the Diagnosis and Statistical Manual for Mental Disorders (DSM-IV TR and DSM-5) and International Classification of Diseases (ICD-10), after that the questionnaire consists of panic disorder (PD), posttraumatic stress disorder (PTSD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). Finally, we expect that this study will contribute to the standardization and efficiency improvement of KM treatment for anxiety disorders, enabling KMDs to provide the best medical care.

Study Design.
is questionnaire was prepared for KMD and KMNPS to understand the perception and treatment of anxiety disorders. SIS searched for literature published within the last 10 years with the search formula ["anxiety disorder" or "generalized anxiety disorder" or "panic disorder" or "post-traumatic stress disorder" or "social phobia"] and ["professional" or "specialist" or "therap * "] and "survey" in PubMed. Of the 219 search results, 12 relevant studies were selected and referenced in the production of the questionnaire [12][13][14][15][16][17][18][19][20][21][22][23]. ree KMNPS (SIS, SYC, and GWK) and one acupuncture and moxibustion medicine specialist (EJK), totaled four KMDs, participated in drafting. e questionnaire covers demographic characteristics, diagnosis method, treatment method, assessment method, and factors affecting the treatment of anxiety disorders. e draft was made after two conferences. One KMNPS (BSK) and one KMD (HWJ), who had not participated in the drafting, participated in revision. e revised version was finalized after consulting with KMNPS and statisticians who did not participate in the questionnaire production.
e Supplementary Material (available here) shows the entire survey.
is study was approved by the Institutional Review Board of Dongguk University Bundang Korean Hospital in Korea (DUBHIRB2017-0012).

Participants and Procedures.
e questionnaire was distributed to 18,329 KMDs and 165 KMNPSs registered through the Association of Korean Medicine. We used "Surveymonkey," an online survey platform, and the survey was conducted online from December 21, 2016, to December 29, 2016, and was sent twice via e-mail.

Statistical Analysis.
All statistical analyses and data handling were performed using R version 3.4 (R Foundation for Statistical Computing, Vienna, Austria). e Chi-square test of independence was used to identify the statistical significance of characteristic differences between KMDs and KMNPSs groups. e characteristics include diagnostic methods, psychotropic drug use rates, and treatment methods, and treatment-related factors.
We divided the data into two groups, KMD and KMNPS, for comparative analysis, because it was assumed that there would be differences in treatment patterns between the two groups. erefore, we tried to uncover the differences and use them as data to provide a complementary treatment process in the future.  Table 2.

Psychotropic Drug Use Rate in Anxiety Disorder Patients.
e proportion of psychotropic medications in first-visit patients with anxiety disorder is almost the same as 48.31 ± 32.27% of the KMD and 47.88 ± 26.66% of the KMNPS (Table 4).

Treatments of Anxiety Disorder Patients.
e reason why patients with anxiety disorder wants to be treated with oriental medicine is to stop or reduce the treatment of drugs (56.0% and 80.0%), improvement of physical symptoms (47.6% and 78.8%), improvement of psychological symptoms (46.4% and 61.3%), and the quality of life (46.4% and 43.8%) in both the KMD and the KMNPS. KMNPS answered significantly (p < 0.001) more in the improvement of physical symptoms and stop medication or decrease dosage (Table 5). e most common treatment for anxiety disorder in both KMD and KMNPS is acupuncture (KMD 95.9% and KMNPS 98.8%) and herbal decoction (KMD 85.1% and KMNPS 91.3%). In the KMD, treatments are used in the order of dry cupping (71.5%), moxibustion (48.6%), pharmaco-acupuncture (24.8%). In the KMNPS, treatments are used in the order of psychotherapy (71.3%), moxibustion (60.0%), and NHIS exclusion herbal extracts (45.0%). Electroacupuncture, NHIS-excluded herbal extracts, wet cupping, aromatherapy, and physical therapy were significantly (p < 0.001) more used in KMNPS (Table 6).
e factors that interfere with the treatment of patients with anxiety disorders are patient symptom characteristics (49.9%), patient lifestyle (44.6%), patient family problem (43.9%), and patient personality characteristics (39.6%) in KMD. In the case of KMNPS, the factors are patient family problem (68.8%), patient personality characteristics (52.5%), patient symptom characteristics (46.2%), and patient lifestyle and slow treatment effect (37.5%). ere was a significant difference (p < 0.001) in the patient family problems, which was highly answered by KMNPS (Table 9).
KMD chose the use of diagnostic tools the most (79.6%) as an area requiring additional education in the treatment of anxiety disorder and was significantly higher than KMNPS (p < 0.001). On the other hand, KMNPS answered psychotherapy (62.5%) as the most important additional education. Results are shown in Table 10.

Discussion
Before discussing the survey results, the KMD and KMNPS survey response rates were very different, 3.69% and 48.5%, respectively. Since the subject of the survey is anxiety disorders, one of the most frequent diseases in the psychiatric Evidence-Based Complementary and Alternative Medicine   field, KMNPS majoring in psychiatry seems to have higher interest and response rates of the questionnaire than KMD.
In the demographic context, KMNPS accounted for the highest percentage in the 30 s because the KMNPS began to produce in 2000 and have had a shorter history. In the case of KMNPS, there were a relatively large number of workers working at the KM Hospital which has specialized departments. e relatively large number of doctor and master degree holder in the specialist are seen as an effort to have medical expertise (Table 1). e assessment is as follows. As a diagnostic/evaluation tool used with anxiety disorders, both KMD and KMNPS account for a high proportion of self-evaluation of patients and information acquisition through counseling. Unlike KMD, KMNPS is more likely to use objective indicators such as DSM/ICD diagnostic criteria, questionnaires, and        (Table 3). is can be seen as securing more patient information and providing objectivity of secured information. e rate of psychotropic medication in patients with anxiety disorder was 48% in both groups, and the reason seems that the severity of the symptoms of anxiety disorder patients coming to KMD and KMNPS for treatment is considered to be the same (Table 4). e reason for choosing KM treatment for anxiety disorders is the improvement of psychological and physical symptoms, along with cutting off or reducing the amount of psychotropic drugs. Although psychotropic medication is a universal treatment for the treatment of anxiety disorders, patients are often found to seek Korean medicine for reducing their reliance on psychotropic drugs or as an alternative treatment for adverse drug reactions (Table 5).

Evidence-Based Complementary and Alternative Medicine
For the treatment tools used in the treatment of anxiety disorders, both KMD and KMNPS selected the treatment tools commonly used in Korean medicine such as acupuncture and herbal medicine. However, KMNPS relatively chose psychotherapy which requires professionalism in terms of its application (Table 6). e most commonly used methods for evaluating the effectiveness of treatments are self-evaluation of patients and counseling in both KMD and KMNPS. In addition, KMNPS are more likely to use objective indicators such as psychotropic drug doses and changes in psychological scale measures; it is consistent with the characteristics that use objective indicators (Tables 3 and 7).
For the important factors in the treatment of anxiety disorders, both groups regarded herbal medicine treatment as the most important. While KMD emphasized herbal medicine treatment and rapport formation at an equal level, in the case of KMNPS, the treatment of herbal medicine is the most important, followed by the patient's temperament and the rapport formation (Table 8). KMNPS tend to prefer psychotherapy over KMD in the treatment of anxiety disorders (Table 6) and seem to focus on resources and making cooperative relationship with patients.
In questionnaire of the disturbances in the treatment of anxiety disorders, both groups reported that the various factors presented are meaningful. In KMNPS, the family problems, personality characteristics, accompanying physical illnesses, and slow treatment effects are considered as obstacles. In particular, the family problems and personality characteristics of patients are 68.8% and 52.5%, respectively, that is over half of them (Table 9). While current symptoms are the most important factor for KMD, KMNPS tends to place greater importance on family problems and personality traits in patients. Just as KMNPS consider the patient's temperament as an important factor in treatment, they can be thought to focus on factors that are more problematic than the symptoms themselves.
Finally, in the additional educational items that they think are necessary, KMD choose utilizing diagnostic tools the most and KMNPS choose psychotherapy the most (Table 10).
is may mean that KMD is not accustomed to the Western neuropsychiatric diagnosis as compared to KMNPS. In the case of KMNPS, since they mainly used psychotherapy to treat patients with anxiety disorders (Table 6), so the need for new psychotherapeutic education appears to be for additional expertise.
ere are several limitations in this survey. We surveyed the current state of KM treatment for anxiety disorders only in Korea. erefore, China, Japan, and many other countries using traditional Asian medicine (TAM) have not been able to figure out how they perceive and treat anxiety disorders. In addition, this was an overview of how KMDs diagnose, treat, and evaluate anxiety disorders. It does not include specific and practical contents such as which acupuncture points, prescriptions, or psychotherapies are used frequently. erefore, various treatment methods and patterns that are used empirically in the clinical field should be additionally considered in future survey for development of CPG.
is study is the first study on the current state of the medical practice of the TAM psychiatrist in Korea. e guideline currently under development will include the characteristics such as the rate of anxiety disorders patients in KM institution, their psychotropic drug use, and KM treatment tool type and utilization tendency. And this study illustrated the differences between KMD and KMNPS for anxiety disorders, so that it was possible to check what is needed to improve the ability for treating anxiety disorders. In the future, based on the results of this study, statistical studies of other diseases are also expected to be more diverse and in-depth analysis than before through comparison of specialists and general practitioners.

Conclusions
is study is the first study to analyze the current state of anxiety disorder treatment in KMDs. KMD and KMNPS showed similar patterns in the perception, diagnosis, and treatment of anxiety disorders, as both are studied and trained in the same oriental medicine. However, the KMNPS is more likely to use objective indicators and psychotherapies as they have been trained in neuropsychiatry for three years and has had experience in applying expertise to the treatment of anxiety disorders. Further clinical research is required to develop clinical guidelines utilized by KMD and KMNPS, respectively.