Using acupuncture to treat depression: a feasibility study

Potential advantages of combining randomized controlled trials with qualitative research in mood and anxiety disorders - A systematic review

INTRODUCTION

Most randomized controlled trials (RCTs) of mood and anxiety disorders employ solely quantitative methods. Supplementing quantitative data with qualitative methods, a so-called mixed-method approach, would seem useful, however this area has not been rigorously reviewed. We undertook a systematic review of RCTs of mood and anxiety disorders that employed concurrent quantitative data collection and qualitative methods exploring the participants' perspective, with the aim of 1. determining the number of such studies, 2. describing study characteristics, and 3. identifying potential advantages of a mixed-method approach.

METHODS

Following PRISMA guidelines, a systematic literature search for RCTs of mood and anxiety disorders, concurrently applying quantitative and qualitative methods, was conducted using EMBASE, PsycINFO and Pubmed, from their inception to February 2021. Categories of potential advantages of this mixed method approach were developed.

RESULTS

A total of 45 RCTs were included. The qualitative components typically included 10-40 participants, mostly consisting of interviews after the intervention. The majority of papers did not state a specific rationale for using a mixed method approach. Four categories of advantages emerged: 1. determine acceptability/feasibility, 2. investigate efficacy, 3. inform implementation in clinical practice and 4. generate new hypotheses based on the combination of quantitative and qualitative data.

LIMITATIONS

Lack of cross-referencing and consistent terminology challenged identification of relevant publications.

CONCLUSION

There are a number of potential advantages of applying mixed method approaches in RCTs within psychiatric research. Intentional consideration of such advantages early in trial design may increase the likelihood of gaining added value.

Efficacy and safety of acupuncture for depression: A systematic review and meta-analysis

Acupuncture is widely accepted as a therapeutic option for managing depression. However, evidence from clinical trials remains controversial. This review aims to synthesize the best available evidence on the efficacy and safety of acupuncture in managing depression. The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Five databases and the relevant trial registries were searched from the inception to October 2021. Randomized clinical trials of acupuncture for managing depression, published in English, were selected for inclusion. The quality of included studies was assessed using the Cochrane risk of bias tool. Netmeta and dmetar of R packages were used to conduct a network meta-analysis. Twenty-two trials with 2391 participants were eligible and included in the analysis. This review found evidence that electroacupuncture (EA) plus antidepressant achieved superior outcomes compared with the waitlist (standardized mean difference = -8.86, 95% confidence interval: -14.78 to -2.93). The treatment ranking of different interventions in improving depression symptoms indicated that EA plus antidepressant with a probability of 0.8294, followed by manual acupuncture (MA) plus antidepressant (0.6470) and MA (0.5232). Acupuncture, either in isolation or as an adjunct to pharmacological treatment, has clinical benefits and can be considered a safe option for managing depression.

Acupuncture for Depression: A Systematic Review and Meta-Analysis

Background: Depression is commonly treated with anti-depressant medication and/or psychological interventions. Patients with depression are common users of complementary therapies, such as acupuncture, either as a replacement for, or adjunct to, their conventional treatments. This systematic review and meta-analysis examined the effectiveness of acupuncture in major depressive disorder. Methods: A search of English (Medline, PsychINFO, Google Scholar, and CINAL), Chinese (China National Knowledge Infrastructure Database (CNKI) and Wanfang Database), and Korean databases was undertaken from 1980 to November 2018 for clinical trials using manual, electro, or laser acupuncture. Results: Twenty-nine studies including 2268 participants were eligible and included in the meta-analysis. Twenty-two trials were undertaken in China and seven outside of China. Acupuncture showed clinically significant reductions in the severity of depression compared to usual care (Hedges (g) = 0.41, 95% confidence interval (CI) 0.18 to 0.63), sham acupuncture (g = 0.55, 95% CI 0.31 to 0.79), and as an adjunct to anti-depressant medication (g = 0.84, 95% CI 0.61 to 1.07). A significant correlation between an increase in the number of acupuncture treatments delivered and reduction in the severity of depression (p = 0.015) was found. Limitations: The majority of the included trials were at a high risk of bias for performance blinding. The applicability of findings in Chinese populations to other populations is unclear, due to the use of a higher treatment frequency and number of treatments in China. The majority of trials did not report any post-trial follow-up and safety reporting was poor. Conclusions: Acupuncture may be a suitable adjunct to usual care and standard anti-depressant medication.

The Effects of Acupuncture on Glutamatergic Neurotransmission in Depression, Anxiety, Schizophrenia, and Alzheimer's Disease: A Review of the Literature

Neuropsychiatric disorders, including depression, anxiety, schizophrenia, and Alzheimer's disease (AD), are diseases that are directly or indirectly associated with cerebral dysfunction and contribute significantly to disability in adult populations worldwide. Important limitations surround the currently available pharmacologic agents for neuropsychiatric disorders and, moreover, many patients fail to respond to these therapies. Acupuncture might be a complementary therapy for neuropsychiatry disorders. In this review, we investigate the current evidence for the treatment efficacy of acupuncture in depression, anxiety, schizophrenia, and AD. Secondly, we review recent advances in understanding of the dysregulated glutamate system underlying the pathophysiology of these disorders. Finally, we discuss the ways in which acupuncture treatment can potentially modulate glutamate receptors and excitatory amino acid transporters. We conclude that the treatment effects of acupuncture may be underpinned by its intervention in the dysregulated glutamate system. Further preclinical and clinical studies are needed to clarify the possible mechanisms of acupuncture in these neuropsychiatric disorders and to establish protocols for treatment guidelines.

Acupuncture for depression

BACKGROUND

Depression is recognised as a major public health problem that has a substantial impact on individuals and on society. People with depression may consider using complementary therapies such as acupuncture, and an increasing body of research has been undertaken to assess the effectiveness of acupuncture for treatment of individuals with depression. This is the second update of this review.

OBJECTIVES

To examine the effectiveness and adverse effects of acupuncture for treatment of individuals with depression.To determine:• Whether acupuncture is more effective than treatment as usual/no treatment/wait list control for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than control acupuncture for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than pharmacological therapies for treating and improving quality of life for individuals with depression.• Whether acupuncture plus pharmacological therapy is more effective than pharmacological therapy alone for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than psychological therapies for treating and improving quality of life for individuals with depression.• Adverse effects of acupuncture compared with treatment as usual/no treatment/wait list control, control acupuncture, pharmacological therapies, and psychological therapies for treatment of individuals with depression.

SEARCH METHODS

We searched the following databases to June 2016: Cochrane Common Mental Disorders Group Controlled Trials Register (CCMD-CTR), Korean Studies Information Service System (KISS), DBPIA (Korean article database website), Korea Institute of Science and Technology Information, Research Information Service System (RISS), Korea Med, Korean Medical Database (KM base), and Oriental Medicine Advanced Searching Integrated System (OASIS), as well as several Korean medical journals.

SELECTION CRITERIA

Review criteria called for inclusion of all published and unpublished randomised controlled trials comparing acupuncture versus control acupuncture, no treatment, medication, other structured psychotherapies (cognitive-behavioural therapy, psychotherapy, or counselling), or standard care. Modes of treatment included acupuncture, electro-acupuncture, and laser acupuncture. Participants included adult men and women with depression diagnosed by Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), Research Diagnostic Criteria (RDC), International Statistical Classification of Diseases and Related Health Problems (ICD), or Chinese Classification of Mental Disorders Third Edition Revised (CCMD-3-R). If necessary, we used trial authors' definitions of depressive disorder.

DATA COLLECTION AND ANALYSIS

We performed meta-analyses using risk ratios (RRs) for dichotomous outcomes and standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Primary outcomes were reduction in the severity of depression, measured by self-rating scales or by clinician-rated scales, and improvement in depression, defined as remission versus no remission. We assessed evidence quality using the GRADE method.

MAIN RESULTS

This review is an update of previous versions and includes 64 studies (7104 participants). Most studies were at high risk of performance bias, at high or unclear risk of detection bias, and at low or unclear risk of selection bias, attrition bias, reporting bias, and other bias.Acupuncture versus no treatment/wait list/treatment as usualWe found low-quality evidence suggesting that acupuncture (manual and electro-) may moderately reduce the severity of depression by end of treatment (SMD -0.66, 95% CI -1.06 to -0.25, five trials, 488 participants). It is unclear whether data show differences between groups in the risk of adverse events (RR 0.89, 95% CI 0.35 to 2.24, one trial, 302 participants; low-quality evidence).Acupuncture versus control acupuncture (invasive, non-invasive sham controls)Acupuncture may be associated with a small reduction in the severity of depression of 1.69 points on the Hamilton Depression Rating Scale (HAMD) by end of treatment (95% CI -3.33 to -0.05, 14 trials, 841 participants; low-quality evidence). It is unclear whether data show differences between groups in the risk of adverse events (RR 1.63, 95% CI 0.93 to 2.86, five trials, 300 participants; moderate-quality evidence).Acupuncture versus medicationWe found very low-quality evidence suggesting that acupuncture may confer small benefit in reducing the severity of depression by end of treatment (SMD -0.23, 95% CI -0.40 to -0.05, 31 trials, 3127 participants). Studies show substantial variation resulting from use of different classes of medications and different modes of acupuncture stimulation. Very low-quality evidence suggests lower ratings of adverse events following acupuncture compared with medication alone, as measured by the Montgomery-Asberg Depression Rating Scale (MADRS) (mean difference (MD) -4.32, 95% CI -7.41 to -1.23, three trials, 481 participants).Acupuncture plus medication versus medication aloneWe found very low-quality evidence suggesting that acupuncture is highly beneficial in reducing the severity of depression by end of treatment (SMD -1.15, 95% CI -1.63 to -0.66, 11 trials, 775 participants). Studies show substantial variation resulting from use of different modes of acupuncture stimulation. It is unclear whether differences in adverse events are associated with different modes of acupuncture (SMD -1.32, 95% CI -2.86 to 0.23, three trials, 200 participants; very low-quality evidence).Acupuncture versus psychological therapyIt is unclear whether data show differences between acupuncture and psychological therapy in the severity of depression by end of treatment (SMD -0.5, 95% CI -1.33 to 0.33, two trials, 497 participants; low-quality evidence). Low-quality evidence suggests no differences between groups in rates of adverse events (RR 0.62, 95% CI 0.29 to 1.33, one trial, 452 participants).

AUTHORS' CONCLUSIONS

The reduction in severity of depression was less when acupuncture was compared with control acupuncture than when acupuncture was compared with no treatment control, although in both cases, results were rated as providing low-quality evidence. The reduction in severity of depression with acupuncture given alone or in conjunction with medication versus medication alone is uncertain owing to the very low quality of evidence. The effect of acupuncture compared with psychological therapy is unclear. The risk of adverse events with acupuncture is also unclear, as most trials did not report adverse events adequately. Few studies included follow-up periods or assessed important outcomes such as quality of life. High-quality randomised controlled trials are urgently needed to examine the clinical efficacy and acceptability of acupuncture, as well as its effectiveness, compared with acupuncture controls, medication, or psychological therapies.

Factors affecting recruitment into depression trials: Systematic review, meta-synthesis and conceptual framework

BACKGROUND

Depression is common and clinical trials are crucial for evaluating treatments. Difficulties in recruiting participants into depression trials are well-documented, yet no study has examined the factors affecting recruitment. This review aims to identify the factors affecting recruitment into depression trials and to develop a conceptual framework through systematic assessment of published qualitative research.

METHODS

Systematic review and meta-synthesis of published qualitative studies. Meta-synthesis involves a synthesis of themes across a number of qualitative studies to produce findings that are "greater than the sum of the parts". ASSIA, CINAHL, Embase, Medline and PsychInfo were searched up to April 2013. Reference lists of included studies, key publications and relevant reviews were also searched. Quality appraisal adopted the "prompts for appraising qualitative research".

RESULTS

7977 citations were identified, and 15 studies were included. Findings indicate that the decision to enter a depression trial is made by patients and gatekeepers based on the patient׳s health state at the time of being approached to participate; on their attitude towards the research and trial interventions; and on the extent to which patients become engaged with the trial. Our conceptual framework highlights that the decision to participate by both the patient and the gatekeeper involves a judgement between risk and reward.

LIMITATIONS

Only English language publications were included in this review.

CONCLUSIONS

Findings from this review have implications for the design of interventions to improve recruitment into depression trials. Such interventions may aim to diminish the perceived risks and increase the perceived rewards of participation.

Improvement in quality of life in depressed patients following verum acupuncture or electroacupuncture plus paroxetine: A randomized controlled study of 157 cases

Depressed patients with scores of 17 or more on the 17 items of the Hamilton Depression Rating Scale were treated with the antidepressant drug paroxetine. They also underwent verum acupuncture or electroacupuncture at Baihui (GV20) and Yintang (GV29). The World Health Organization Quality of Life Scale Brief Version showed a significant increase in the total scores of patients who underwent verum acupuncture and electroacupuncture for 6 weeks compared with those who were given paroxetine only; significantly increased physical domain and social relationship scores in verum acupuncture patients compared with paroxetine only; and significantly elevated psychological domain scores with electroacupuncture compared with paroxetine only. These results indicate that both verum acupuncture and electroacupuncture can improve quality of life in depressed patients undergoing paroxetine treatment.

Cost-effectiveness analysis of acupuncture, counselling and usual care in treating patients with depression: the results of the ACUDep trial

BACKGROUND

New evidence on the clinical effectiveness of acupuncture plus usual care (acupuncture) and counselling plus usual care (counselling) for patients with depression suggests the need to investigate the health-related quality of life and costs of these treatments to understand whether they should be considered a good use of limited health resources.

METHODS AND FINDINGS

The cost-effectiveness analyses are based on the Acupuncture, Counselling or Usual care for Depression (ACUDep) trial results. Statistical analyses demonstrate a difference in mean quality adjusted life years (QALYs) and suggest differences in mean costs which are mainly due to the price of the interventions. Probabilistic sensitivity analysis is used to express decision uncertainty. Acupuncture and counselling are found to have higher mean QALYs and costs than usual care. In the base case analysis acupuncture has an incremental cost-effectiveness ratio (ICER) of £4,560 per additional QALY and is cost-effective with a probability of 0.62 at a cost-effectiveness threshold of £20,000 per QALY. Counselling compared with acupuncture is more effective and more costly with an ICER of £71,757 and a probability of being cost-effective of 0.36. A scenario analysis of counselling versus usual care, excluding acupuncture as a comparator, results in an ICER of £7,935 and a probability of 0.91.

CONCLUSIONS

Acupuncture is cost-effective compared with counselling or usual care alone, although the ranking of counselling and acupuncture depends on the relative cost of delivering these interventions. For patients in whom acupuncture is unavailable or perhaps inappropriate, counselling has an ICER less than most cost-effectiveness thresholds. However, further research is needed to determine the most cost-effective treatment pathways for depressed patients when the full range of available interventions is considered.

Effects of electroacupuncture on depression and the production of glial cell line-derived neurotrophic factor compared with fluoxetine: a randomized controlled pilot study

BACKGROUND AND OBJECTIVE

Postmortem studies indicate that the number and density of glial cells are reduced in different brain regions of patients with depression. Glial cell line-derived neurotrophic factor (GDNF) plays an important role in the pathogenesis of depressive disorder (DD) and might be a biomarker for damage to nerve cells. In this study, we compared the therapeutic effects of electroacupuncture (EA) and fluoxetine, a serotonin reuptake inhibitor, on DD patients, focusing on the serum level of GDNF.

DESIGN

This was a prospective, randomized clinical trial.

SETTING

Seventy-five patients with DD from the Department of Acupuncture, Beijing Hospital of Traditional Chinese Medicine, were recruited.

INTERVENTION

Twenty patients were treated with acupuncture for 6 weeks on the acupoints of Baihui (DU20) and Zusanli (ST36). Sixteen patients were treated with acupuncture for 6 weeks on the acupoints of Taichong (LR3), Sanyinjiao (SP6), Neiguan (PC6), and Shenmen (HT7), and constituted the electroacupuncture control group. The patients received acupuncture treatment five times per week. Twenty-five patients were treated with oral fluoxetine (20 mg/day) for 6 weeks.

OUTCOME MEASURES

All subjects were evaluated by the Hamilton Depression Rating Scale at four time points (0 [baseline], 2, 4, and 6 weeks after treatment). Serum GDNF was quantified in duplicate by enzyme-linked immunosorbent assay (ELISA).

RESULTS

EA and fluoxetine had similar curative effects on DD patients. EA had a faster onset of action, better response rate, and better improvement rate than fluoxetine. Both fluoxetine and EA treatment restored the normal concentration of GDNF in the serum of DD patients.

CONCLUSION

EA treatment for depression is as effective as a recommended dose of fluoxetine. However, EA demonstrates an advantage in the regulation of the production of GDNF compared with fluoxetine.

Acupuncture and Chinese herbs as treatments for depression: an Australian pilot study

AIMS

Aims were to determine the effectiveness of acupuncture and Chinese herbs as treatments for depression, and to assess beliefs, attitudes and treatment experience.

METHOD

Participants received acupuncture or acupuncture and Chinese herbs combined for five weeks. Acupuncture was given for 30 min twice a week and herbs taken three times a day. A Beliefs and Attitudes questionnaire was administered at baseline and Treatment Experience questionnaire post treatment. Outcome measure was improvement in depressive symptoms at the end of treatment period.

RESULTS

Nineteen participants completed 5 weeks of treatment, 12 in the acupuncture group and 7 in the combined group. Treatment significantly improved depressive symptoms, however, there were no differences between groups. At baseline, participants were positive about the perceived effectiveness of treatment, and treatment experiences were positive.

CONCLUSIONS

Acupuncture was effective in reducing depressive symptoms. However, herbs did not have an additional treatment effect. Beliefs and attitudes were positive.

Acupuncture for depression and myalgia in patients with hepatitis: an observational study

BACKGROUND

Depressive symptoms and myalgia are commonly seen in patients with chronic hepatitis B and chronic hepatitis C.

OBJECTIVE

To investigate the efficacy of acupuncture treatment on depressive symptoms and myalgia in patients with hepatitis.

METHODS

Of 44 patients with hepatitis screened for depression and myalgia, 28 were enrolled and included in the study. The main outcome measure for depressive symptoms was Beck's Depression Inventory (BDI). For pain/myalgia, patients rated their pain on a scale from 0 to 10. Patients with a score greater than the cut-off point in either score were allocated to acupuncture treatment. The Chinese method of acupuncture was used. Treatment continued for 6 weeks.

RESULTS

At baseline, 17/44 patients (39%) had a BDI score ≥17 and 24 (55%) had a pain score ≥5. A total of 28 patients were allocated to acupuncture treatment, forming three groups: group 1, 13 patients with high BDI and high myalgia scores; group 2, 11 patients with low BDI score but high myalgia score; group 3, 4 patients with high BDI score but low myalgia score. Adherence to treatment was good; all patients completed the sessions and there were no drop-outs. Significant improvements in end-treatment BDI and in myalgia scores compared with baseline levels was found.

CONCLUSION

Acupuncture seems to be a promising treatment for patients with hepatitis. Further studies are warranted in large populations to establish the therapeutic role of acupuncture.

Acupuncture for depression

BACKGROUND

There is interest from the community in the use of self help and complementary therapies for depression. This review examined the currently available evidence supporting the use of acupuncture to treat depression.

OBJECTIVES

To examine the effectiveness and adverse effects of acupuncture in the treatment for depression.

SEARCH STRATEGY

The following databases were searched: CCDAN-CTR, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to Dec 2008), EMBASE (1980 to Dec 2008), PSYCINFO (1874 to Dec 2008), the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL (1980 to Dec 2008), Wan Fang database (to Dec 2008). The following terms were used: depression, depressive disorder, dysthymic disorder and acupuncture.

SELECTION CRITERIA

Inclusion criteria included all published and unpublished randomised controlled trials comparing acupuncture with sham acupuncture, no treatment, pharmacological treatment, other structured psychotherapies (cognitive behavioural therapy, psychotherapy or counselling), or standard care. The following modes of treatment were included: acupuncture, electro acupuncture or laser acupuncture. The participants included adult men and women with depression defined by clinical state description, or diagnosed by the Diagnostic and Statistical Manual (DSM-IV), Research Diagnostic Criteria (RDC), International Classification of Disease (ICD) or the Criteria for Classification and Diagnosis of Mental Diseases CCMD-3-R.

DATA COLLECTION AND ANALYSIS

Meta-analyses were performed using relative risk for dichotomous outcomes and standard mean differences for continuous outcomes, with 95% confidence intervals. Primary outcomes were reduction in the severity of depression, measured by self rating scales, or by clinician rated scales and an improvement in depression defined as remission versus no remission.

MAIN RESULTS

This review is an update and now contains data from 30 studies. Following recent searches, 23 new studies have been added and a further 11 trials were excluded (due to suboptimal doses of medication, no clinical outcomes, insufficient reporting). Thirty trials with 2,812 participants are included in the meta-analysis.There was a high risk of bias in the majority of trials. There was insufficient evidence of a consistent beneficial effect from acupuncture compared with a wait list control or sham acupuncture control. Two trials found acupuncture may have an additive benefit when combined with medication compared with medication alone. A subgroup of participants with depression as a co-morbidity experienced a reduction in depression with manual acupuncture compared with SSRIs (RR 1.66, 95%CI 1.03, 2.68) (three trials, 94 participants). The majority of trials compared manual and electro acupuncture with medication and found no effect between groups.

AUTHORS' CONCLUSIONS

We found insufficient evidence to recommend the use of acupuncture for people with depression. The results are limited by the high risk of bias in the majority of trials meeting inclusion criteria.

Efficacy evaluation for depression with somatic symptoms treated by electroacupuncture combined with Fluoxetine

OBJECTIVE

This study is to investigate the clinical therapeutic effects and safety of treating mild or moderate depression with somatic symptoms with electroacupuncture combined with Fluoxetine.

METHODS

95 cases of mild or moderate depression with somatic symptoms were randomly divided into a Fluoxetine group, and an electroacupuncture plus Fluoxetine group. Hamilton Depression Scale (HAMD) was used for the assessment of clinical therapeutic effects and Treatment Emergent Symptom Scale (TESS) was used for assessment of adverse reactions.

RESULTS

The total effective rate was 77.27% in the Fluoxetine group and 78.26% in the electroacupuncture plus Fluoxetine group, showing no statistically significant difference between these two groups (P > 0.05). However, the treatment took effect after two weeks in the electroacupuncture plus Fluoxetine group but after four weeks in Fluoxetine group. During this time, a better therapeutic effect on depression with mild or moderate somatic symptoms was found in the electroacupuncture plus Fluoxetine group, which also had fewer adverse reactions than the Fluoxetine group.

CONCLUSION

Electroacupuncture combined with Fluoxetine takes effect faster for relieving the somatic symptoms with fewer adverse reactions. It is worth popularizing clinically.