Abstract
Objectives
This study investigated how Korean medicine doctors treat schizophrenia spectrum disorders to assess current practices, identify high-frequency interventions, and evaluate clinical field utilization, aiming to develop evidence-based Korean medicine clinical practice guideline.
Methods
A nationwide cross-sectional survey was conducted in December 2024 among doctors affiliated with the Association of Korean Medicine. Korean medicine doctors who had treated schizophrenia spectrum disorder patients within the past six months were included. The survey assessed treatment goals, patient characteristics, treatment modalities, and assessment methods.
Results
A total of 324 Korean medicine doctors were included in the final analysis. The most frequently reported treatment objective was management of co-existing symptoms (81.8%), followed by complementary treatment for positive/negative symptoms (44.4%) and management of antipsychotic-induced side effects (29.0%). Patients in the chronic (55.2%) and recovery disease phases (50.6%) were more likely to be treated with Korean medicine than patients with acute exacerbation. Herbal medicine (92.9%) and acupuncture (79.6%) were the primary interventions. The most frequently prescribed herbal formulas were Ondam-tang (61.7%), Shihogayonggolmoryo-tang (57.4%), and Ukgan-san (54.9%). GV20 (82.4%), EX-HN1 (58.0%), and HT7 (44.1%) were the most used acupuncture points. The primary co-existing symptoms managed were insomnia (77.2%), depression (76.2%), and agitation/excitement (64.2%). Weight gain (69.8%), dyspepsia (59.3%), and constipation (55.9%) were the most frequently addressed antipsychotic-induced side effects.
Conclusion
This nationwide survey provides foundational data for developing Korean medicine clinical practice guideline for schizophrenia spectrum disorders. The findings revealed that Korean medicine treatment serves a complementary role to conventional antipsychotic medications, primarily focusing on co-existing symptoms and side effect management.
Keywords: schizophrenia, Korea traditional medicine, traditional East Asian Medicine, surveys and questionnaires, cross-sectional studies
INTRODUCTION
Schizophrenia spectrum disorders are characterized by positive symptoms, including delusions, hallucinations, disorganized speech (frequent derailment or incoherence), or disorganized or catatonic behavior, and negative symptoms, such as diminished emotional expression or avolition [1]. The 2016 Mental Health Survey reported that the lifetime prevalence of schizophrenia spectrum disorders in Korea was 0.5%. Notably, approximately 1.8% of the Korean population has experienced schizophrenia-related symptoms, such as auditory or visual hallucinations, at least once in their lifetime [2].
While antipsychotic medication remains essential for schizophrenia spectrum disorder treatment, these medications can cause side effects, including extrapyramidal symptoms, sedation, weight gain, type II diabetes, hyperprolactinemia, metabolic syndrome, dyslipidemia, sexual dysfunction, and cardiovascular effects [3]. While positive symptoms are often effectively controlled with antipsychotic drugs, negative symptoms frequently remain inadequately addressed [4]. Korean medicine treatments, including herbal medicine, acupuncture, moxibustion, qigong, and meditation, may effectively address antipsychotic medication side effects and improve negative symptoms in patients with schizophrenia spectrum disorders [5-7].
The Korean Medicine Innovation Technology Development Project [8], a national research and development initiative by the Ministry of Health and Welfare that began in 2000, supports various research subcategories, including Clinical Practice Guideline (CPG) development [9]. In 2024, the Project elected to prioritize the development of a standardized Korean medicine CPG for schizophrenia spectrum disorders. As part of the developmental process for these guidelines, this study conducted a clinical field survey analyzing Korean medicine doctors who treat schizophrenia spectrum disorders.
This nationwide survey aimed to investigate the current status of Korean medicine treatment for schizophrenia spectrum disorders among Korean medicine doctors to: 1) Assess current practices, 2) Identify high-frequency interventions for core clinical question development, and 3) Evaluate clinical field utilization to determine grade recommendations in the Korean medicine standardized CPG for schizophrenia spectrum disorders.
MATERIALS AND METHODS
1. Study design
This was a nationwide, cross-sectional survey investigating how Korean medicine doctors treat schizophrenia spectrum disorders in South Korea. This study adopted a census-style recruitment approach, distributing a survey in December 2024 via email and text message to all Korean medicine doctors affiliated with the Association of Korean Medicine without a priori sample size calculation. The study protocol was approved by the Institutional Review Board of the Korea Institute of Oriental Medicine (IRB No. I-2409/009-002). The survey data collection period was from December 17-31, 2024.
2. Participants
The inclusion criteria for this study were Korean medicine doctors who had treated one or more patients with schizophrenia spectrum disorders within the past six months and who voluntarily agreed to participate in this study. The purpose and content of the research were explained on the first page of the survey, and only those who agreed to participate were allowed to proceed with the questionnaire.
3. Development of survey questionnaire
A self-reported, web-based survey was developed to assess the current status of Korean medicine treatment for schizophrenia spectrum disorders. The survey collected demographic information, including participants’ sex, age group, years since Korean medicine license acquisition, practice location, type of workplace, type of Korean medicine doctor license, and number of schizophrenia spectrum disorder patients treated within the last six months. The survey questionnaire consisted of five main sections as outlined in Table 1.
Table 1.
Survey questionnaire sections and contents
| Section | Topic | Main contents |
|---|---|---|
| A | Treatment goals and patient characteristics | · Main objectives of Korean medicine treatment · Characteristics of patients who frequently visit Korean medicine institutions or show effective treatment response |
| B | Complementary treatment for positive and negative symptoms | · Frequently used/effective Korean medicine treatments · Commonly prescribed herbal formulas · Commonly used acupuncture points |
| C | Management of co-existing symptoms | · Co-existing symptoms frequently seen or effectively treated · Commonly prescribed formulas for agitation/excitement, depression, and insomnia |
| D | Management of antipsychotic-induced side effects | · Side effects frequently seen or effectively treated · Commonly prescribed formulas for weight gain, metabolic syndrome, hyperprolactinemia/amenorrhea, constipation, extrapyramidal symptoms, and tardive dyskinesia |
| E | Treatment protocols and assessment methods | · Korean medicine treatment duration · Evaluation intervals · Commonly used assessment tools |
4. Statistical analysis
Descriptive statistical analysis was performed for all survey items, including participants’ general characteristics, using R version 4.4.3 [10]. Results were presented as frequencies and percentages (%).
RESULTS
1. Participants’ characteristics
The survey was distributed to Korean medicine doctors affiliated with the Association of Korean Medicine via text messages (n = 27,365) and emails (n = 25,795). Of the 543 respondents who agreed to participate, 120 were excluded for not treating schizophrenia spectrum disorder patients within the past six months. Additionally, 99 were excluded for incomplete survey responses, resulting in 324 final participants (Fig. 1). Most participants were male (70.1%) and in their thirties or forties (67.0%). Only a small proportion (4.3%) worked in neuropsychiatry-specialized Korean medicine clinics. Most participants (55.6%) treated fewer than one schizophrenia spectrum disorder patient per three months, but at least one per six months (Table 2).
Figure 1.
Study participant flowchart.
Table 2.
Demographic characteristics of participants (n = 324)
| Characteristic | N (%) |
|---|---|
| Sex | |
| Male | 227 (70.1%) |
| Female | 97 (29.9%) |
| Age (years) | |
| < 30 | 22 (6.8%) |
| ≥ 30 to < 40 | 102 (31.5%) |
| ≥ 40 to < 49 | 115 (35.5%) |
| ≥ 50 to < 59 | 69 (21.3%) |
| ≥ 60 | 16 (4.9%) |
| Clinical experience (years) | |
| < 5 | 34 (10.5%) |
| ≥ 5 to < 10 | 71 (21.9%) |
| ≥ 10 to < 15 | 83 (25.6%) |
| ≥ 15 to < 20 | 40 (12.3%) |
| ≥ 20 to < 30 | 68 (21.0%) |
| ≥ 30 | 28 (8.6%) |
| Practice location | |
| Capital region (Seoul metropolitan area) | 183 (56.5%) |
| Non-capital area | 141 (43.5%) |
| Type of workplace | |
| General clinic | 226 (69.8%) |
| Neuropsychiatry-specialized clinic | 14 (4.3%) |
| Hospital | 53 (16.4%) |
| Public medical institution | 9 (2.8%) |
| Long-term care hospital | 19 (5.9%) |
| Others | 1 (0.3%) |
| Type of KMD license | |
| General practitioner | 246 (75.9%) |
| Specialist | 73 (22.5%) |
| Dual license holder | 5 (1.5%) |
| Number of SSD patients treated in past 6 months | |
| ≥ 1 per week | 24 (7.4%) |
| ≥ 1 per month (< 1 per week) | 57 (17.6%) |
| ≥ 1 per 2 months (< 1 per month) | 27 (8.3%) |
| ≥ 1 per 3 months (< 1 per 2 months) | 36 (11.1%) |
| ≥ 1 per 6 months (< 1 per 3 months) | 180 (55.6%) |
KMD, Korean medicine doctor; SSD, schizophrenia spectrum disorders.
2. Treatment goal and patient characteristics
The most frequently reported objective of Korean medicine treatment was management of co-existing symptoms (81.8%), followed by complementary treatment for positive and negative symptoms (44.4%) and management of antipsychotic-induced side effects (29.0%). Additionally, six participants reported that treating musculoskeletal symptoms, such as pain, was their primary treatment goal for schizophrenia spectrum disorder patients. Patients in the chronic (55.2%) or recovery (50.6%) phases of disease most frequently visited Korean medicine institutions and had a more effective treatment response, compared to newly diagnosed and treated patients. Negative symptom-predominant patients (28.1%) were more frequently reported than positive symptom-predominant patients (9.0%) (Table 3).
Table 3.
Treatment objectives and clinical characteristics
| Characteristic | N (%) |
|---|---|
| Main objectives of Korean medicine treatment | |
| Complementary treatment for positive and negative symptoms |
144 (44.4%) |
| Management of co-existing symptoms | 265 (81.8%) |
| Management of antipsychotic-induced side effects | 94 (29.0%) |
| Characteristics of patients frequently seen or effectively treated |
|
| Prodromal phase | 134 (41.4%) |
| Acute phase | 32 (9.9%) |
| Recovery phase | 164 (50.6%) |
| Treatment-resistant schizophrenia | 56 (17.3%) |
| Chronic schizophrenia | 179 (55.2%) |
| Positive symptom-predominant | 29 (9.0%) |
| Negative symptom-predominant | 91 (28.1%) |
| Co-existing symptoms frequently seen or effectively treated |
|
| Agitation/Excitement | 208 (64.2%) |
| Depression | 247 (76.2%) |
| Insomnia | 250 (77.2%) |
| Antipsychotic-induced side effects frequently seen or effectively treated |
|
| Weight gain | 226 (69.8%) |
| Metabolic abnormalities | 150 (46.3%) |
| Hyperprolactinemia/amenorrhea | 50 (15.4%) |
| Constipation | 181 (55.9%) |
| Extrapyramidal symptoms | 36 (11.1%) |
| Tardive dyskinesia | 28 (8.6%) |
| Cardiovascular side effects | 62 (19.1%) |
| Sexual dysfunction | 38 (11.7%) |
| Hepatic impairment | 39 (12.0%) |
| Leukopenia | 9 (2.8%) |
| Hypersalivation | 15 (4.6%) |
| Dyspepsia | 192 (59.3%) |
| Anticholinergic side effects | 37 (11.4%) |
| Excessive sedation | 101 (31.2%) |
Multiple selections allowed.
3. Complementary treatment for positive and negative symptoms
Herbal medicine (92.9%) and acupuncture (79.6%) were the most frequently used treatments (Fig. 2). The most commonly prescribed herbal medicine formulas were Ondam-tang (61.7%), Shihogayonggolmoryo-tang (57.4%), and Ukgan-san (54.9%), with decoction as the predominant form (92.6%). For acupuncture, GV20 (82.4%), EX-HN1 (58.0%), and HT7 (44.1%) were the most frequently used points (Table 4).
Figure 2.
Frequently used/effective Korean medicine treatments (multiple selections allowed).
Table 4.
Commonly prescribed herbal formulas and acupoints
| Characteristic | N (%) |
|---|---|
| Commonly prescribed herbal formulas | |
| Ondam-tang | 200 (61.7%) |
| Dodam-tang | 46 (14.2%) |
| Hwangryeonhaedok-tang | 78 (24.1%) |
| Ukgan-san | 178 (54.9%) |
| Shihogayonggolmoryo-tang | 186 (57.4%) |
| Soyo-san | 120 (37.0%) |
| Hyeolbuchukeuo-tang | 20 (6.2%) |
| Yukgunja-tang | 19 (5.9%) |
| Commonly used herbal forms | |
| Decoction (individually prepared) | 300 (92.6%) |
| Granule (individually prepared) | 63 (19.4%) |
| Pill (individually prepared) | 36 (11.1%) |
| Non-covered herbal medicine product | 46 (14.2%) |
| Insurance-covered herbal medicine product | 35 (10.8%) |
| Commonly used acupuncture points | |
| Head and neck: GV20 | 267 (82.4%) |
| Head and neck: EX-HN1 | 188 (58.0%) |
| Head and neck: GV24 | 74 (22.8%) |
| Head and neck: EX-HN3 | 78 (24.1%) |
| Head and neck:GB20 | 113 (34.9%) |
| Head and neck:TE17 | 85 (26.2%) |
| Upper limbs: LI4 | 138 (42.6%) |
| Upper limbs: PC6 | 139 (42.9%) |
| Upper limbs:HT7 | 143 (44.1%) |
| Lower limbs: ST36 | 122 (37.7%) |
| Lower limbs: GB34 | 33 (10.2%) |
| Lower limbs: ST40 | 21 (6.5%) |
| Lower limbs: SP6 | 98 (30.2%) |
| Lower limbs: LR3 | 121 (37.3%) |
| Lower limbs: KI3 | 38 (11.7%) |
| Abdominal: CV12 | 95 (29.3%) |
| Abdominal: CV4 | 55 (17.0%) |
Multiple selections allowed.
4. Management of co-existing symptoms
Insomnia (77.2%), depression (76.2%), and agitation/excitement (64.2%) were the most frequently treated co-existing symptoms (Table 3). For agitation/excitement, Sasim-tang (55.6%) and Hwangryeonhaedok-tang (41.4%) were most prescribed. For depression, Guibi-tang (51.5%), Ondam-tang (45.7%), and Soyo-san (40.7%) were commonly used. For insomnia, Shihososgan-tang (54.9%) and Hwangryeonhaedok-tang (29.6%) were most frequently prescribed.
5. Management of antipsychotic-induced side effects
Weight gain (69.8%), dyspepsia (59.3%), and constipation (55.9%) were the most frequently addressed side effects (Table 3). For weight gain, Bangpungtongseong-san (50.9%) was most prescribed. Ondam-tang (38.3%) and Banhasasim-tang (36.7%) were commonly used for metabolic abnormalities, and Hyeolbuchukeuo-tang (36.1%) was most prescribed for hyperprolactinemia and amenorrhea. For constipation, Majain-hwan (42.0%) was most frequently used. For extrapyramidal symptoms, Soyo-san (53.1%) was most prescribed, while Ukgan-san (59.0%) was most commonly used for tardive dyskinesia.
6. Treatment protocols and assessment methods
Korean medicine treatment typically lasted six months (34.9%) or one year (26.9%), though durations varied. Participants who selected “Other” when asked about treatment duration reported that treatment was needed for more than two years, possibly lifelong. Evaluation intervals were most frequently conducted at one-month intervals (49.1%), followed by two-week intervals (23.5%). For assessment tools, PANSS was the most commonly used for evaluating psychotic symptoms (33.3%). Additionally, the antipsychotic-induced side effects assessment (41.7%) and medication adherence assessment (29.0%) were also frequently utilized (Table 5).
Table 5.
Treatment protocols and assessment methods
| Characteristic | N (%) |
|---|---|
| Korean medicine treatment duration | |
| 1 month | 6 (1.9%) |
| 2 months | 7 (2.2%) |
| 3 months | 70 (21.6%) |
| 6 months | 113 (34.9%) |
| 1 year | 87 (26.9%) |
| 2 years | 33 (10.2%) |
| Others | 8 (2.5%) |
| Evaluation intervals | |
| 2 weeks | 76 (23.5%) |
| 1 month | 159 (49.1%) |
| 2 months | 22 (6.8%) |
| 3 months | 64 (19.8%) |
| Others | 3 (0.9%) |
| Commonly used assessment tool* | |
| PANSS | 108 (33.3%) |
| BPRS | 62 (19.1%) |
| CGI-S | 72 (22.2%) |
| CGI-I | 67 (20.7%) |
| Antipsychotic-induced side effects assessment |
135 (41.7%) |
| Medication adherence assessment | 94 (29.0%) |
*Multiple selections allowed.
DISCUSSION
1. Current status of Korean medicine treatments for schizophrenia spectrum disorders
This nationwide survey included 324 Korean medicine doctors, representing the status of Korean medicine treatment for schizophrenia spectrum disorders in South Korea. The survey results revealed that herbal medicine (92.9%) and acupuncture (79.6%) were the primary treatment modalities. The main objective of Korean medicine treatment was management of co-existing symptoms (81.8%), followed by complementary treatment for positive and negative symptoms (44.4%) and management of antipsychotic-induced side effects (29.0%). All three objectives reflect how Korean medicine treatment may benefit patients when used in conjunction with antipsychotic medication.
Chronic (55.2%) and recovery phase (50.6%) schizophrenia spectrum disorder patients were most likely to receive Korean medicine. Previous systematic reviews have examined herbal medicine treatment for chronic schizophrenia [11] and treatment-resistant schizophrenia [12]. These results suggested that Korean medicine treatment primarily targets chronic and recovery phase patients with predominantly negative symptoms, rather than acute phase patients struggling with positive symptoms.
In herbal medicine treatment, providers preferred decoction over other herbal forms (92.6%), with the most frequently used prescriptions being Ondam-tang (61.7%), Shihogayonggolmoryo-tang (57.4%), and Ukgan-san (54.9%). This is consistent with a randomized controlled trial analysis of traditional Chinese medicine use in schizophrenia, where Wendan decoction (Ondam-tang in Korean) was the most frequently used herbal prescription [13]. In that study, Shugan Jieyu capsule and Jieyu Anshen-tang were the next most reported prescriptions.
Regarding acupuncture, GV20, EX-HN1, and HT7 were the most used acupoints in our study. This is consistent with an exploratory study on acupoints with potential for schizophrenia treatment, which reported that GV20, PC6, GV29, ST36, SP6, LI4, LR3, ST40, HT7, EX-HN1, GV24, and GV26 were frequently used acupoints [14].
For management of co-existing symptoms, insomnia (77.2%), depression (76.2%), and agitation/excitement (64.2%) were the main treatment targets. Insomnia has been associated with worsening clinical symptoms in schizophrenia patients [15]. Depression is particularly concerning, as suicide represents the highest cause of death in schizophrenia patients, with a 13-fold higher risk compared to the general population [16]. Therefore, effective management of these co-existing symptoms is crucial in schizophrenia spectrum disorders, and Korean medicine treatment can play an important role.
Regarding antipsychotic-induced side effect management, weight gain (69.8%), dyspepsia (59.3%), and constipation (55.9%) were most frequently addressed. Weight gain and metabolic abnormalities are well-known major side effects of antipsychotic medications [17]. These concerns worsen patients’ physical health and reduce antipsychotic medication adherence, further emphasizing the critical role Korean medicine treatment plays in comprehensive care for schizophrenia spectrum disorder.
2. Implications for clinical practice guideline development
Based on the results of this study, the clinical aspects of the CPG were organized according to three Korean medicine treatment objectives: 1) Complementary treatment for positive and negative symptoms, 2) Management of co-existing symptoms, and 3) Management of antipsychotic medication side effects. This reflects the Korean schizophrenia pharmacotherapy guidelines [18] and modifies them to highlight Korean medicine’s unique role, complementary to antipsychotic medications.
High-frequency interventions provide important priority criteria when establishing clinical questions, which are used to develop CPGs. Our study underscores that herbal medications and acupuncture are mainstays of Korean medicine treatment for schizophrenia spectrum disorders in South Korea. As such, it is necessary to formulate clinical questions regarding these methods to develop an accurate and effective CPG. Clinical questions should be developed for Ondam-tang, the most frequently prescribed herbal formula, while consideration should also be given to other high-frequency prescriptions, including Shihogayonggolmoryo-tang and Ukgan-san.
Notably, several clinical studies have exemplified Ondam-tang’s effectiveness for schizophrenia treatment [5], supporting high-priority development of clinical questions for this formula. Ukgan-san has also exhibited promising results in multiple clinical trials for treatment-resistant schizophrenia [19-21], making it an important prescription to consider in CPG development. Systematic evaluation and recommendation development for treatments frequently used in clinical practice will enhance future CPGs’ practical applicability.
3. Clinical field utilization assessment for recommendation grading
When deriving clinical question recommendations in clinical practice guidelines, decisions are based on benefit-harm assessment results and evidence levels. Recommendation grades can be upgraded or downgraded by comprehensively considering clinical field utilization, cost, values, and preferences. Among these, clinical field utilization is assessed considering the following factors: 1) Expert consensus, 2) Clinical field utilization surveys, 3) Inclusion in the Pharmacopoeia of Korean Medicine stipulated by the Ministry of Health and Welfare and Ministry of Food and Drug Safety notices and Korean Medicine University textbooks, and 4) Comprehensive judgment based on data from related organizations, such as the Health Insurance Review & Assessment Service and National Health Insurance Service.
This study provides evidence data corresponding to ‘clinical field utilization surveys.’ The results showed that more than 50% of respondents utilize herbal medicine and acupuncture for schizophrenia spectrum disorder patients, confirming high utilization in clinical practice. This finding provides significant data supporting the importance of determining grades for related recommendations.
4. Limitations
This study has several limitations. First, most participants (55.6%) treated fewer than one patient with schizophrenia spectrum disorder per three-month period, indicating that our findings reflect general Korean medicine practice patterns rather than specialized, neuropsychiatry-focused practice. This limits the generalizability of results to Korean medicine neuropsychiatry specialists, who may employ different treatment approaches based on more extensive clinical experience. Second, the cross-sectional survey study design limits the accuracy and reliability of the results. Third, as a web-based, self-reported survey, this study is subject to recall and social desirability biases and potential inaccuracies in self-reported treatment frequencies and outcomes. To address these limitations, future prospective observational studies, patient registry studies, EMR-based studies, or health insurance data-based studies are needed. Additionally, focus group interviews targeting Korean medicine doctors with extensive experience in treating schizophrenia spectrum disorders are essential.
CONCLUSION
This is the first nationwide survey of Korean medicine treatment for schizophrenia spectrum disorders in Korea. Our data is foundational for developing Korean medicine standardized clinical practice guideline. The study exhibited that Korean medicine treatment serves a complementary role to antipsychotic medications, particularly focusing on the management of co-existing symptoms and side effect mitigation. The findings provide direction for clinical question development based on high-frequency interventions, predominantly herbal medicine and acupuncture, and offer evidence for recommendation grading through clinical field utilization assessment.
Footnotes
AUTHORS’ CONTRIBUTIONS
Conceptualization: Pyung-Wha Kim, Boram Lee, Yujin Choi; Formal analysis: Yujin Choi; Writing – Original draft: Pyung-Wha Kim, Yujin Choi; Writing – Review & Editing: Boram Lee.
ETHICAL APPROVAL
This research was reviewed and approved by the Institutional Review Board (IRB) of Korea Institution of Oriental Medicine (registration number I-2409/009-002, approval date: 2024.11.20.). Informed consent was obtained from all participants.
DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding author upon reasonable request.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest.
FUNDING
This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (RS-2024-00442840).
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