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Sommaire
Post-Stroke Depression
Dépression post-AVC : évaluation de l'acupuncture
1. Systematic Reviews and Meta-Analysis
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Lam 2023
Lam Ching W, Li HJ, Guo J, Yao L, Chau J, Lo S, Yuen CS, Ng BFL, Chau-Leung Yu E, Bian Z, Lau AY, Zhong LL. Acupuncture for post-stroke depression: a systematic review and network meta-analysis. BMC Psychiatry. 2023 May 4;23(1):314. https://doi.org/10.1186/s12888-023-04749-1
| Background | Patients with post-stroke depression (PSD) usually experience anxiety, hopelessness, and insomnia, which have a negative impact on their daily activities and post-stroke rehabilitation. Acupuncture (AC), as a minimally invasive technique, has become a popular choice for improving depression symptoms. However, it is still unclear which therapy is associated with the best outcomes for PSD. In this review, we aimed to explore the impact of AC in alleviating symptoms of PSD and to evaluate the difference in effectiveness between AC combined with pharmacotherapies and various non-pharmacotherapies. |
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| Methods | Six databases and three clinical trials registration platforms were searched from inception to March 2023. Randomized clinical trial comparing needle-based AC with pharmacotherapy, and other non-pharmacotherapy or invalid group were included. Two independent reviewers identified eligible studies, and collected data using a pre-made form. A Bayesian network meta-analysis was conducted to assess and compare different techniques using RStudio 3.6.0 with the package 'GEMTC' V.0.8.1. The primary outcome was the efficacy for PSD assessed by scales measuring depressive symptoms. The secondary outcomes were effectiveness for neurological function and the quality of life. The ranking probabilities for all treatment interventions was performed using the Surface Under the Cumulative Ranking curve (SUCRA). The risk of bias was assessed by using the Revised Cochrane Risk of Bias tool 2. |
| Results | Sixty-two studies, involving 5308 participants published from 2003 to 2022, were included. The results showed that compared with western medicine (WM) (defined as pharmacotherapy for PSD), AC alone or with repetitive transcranial magnetic stimulation (RTMS), Traditional Chinese medicine (TCM) alone or with WM, were superior for alleviating depression symptoms. Compared to Usual Care, AC alone or plus other therapies could significantly decrease scores on the Hamilton Depression Rating scale. According to result of SUCRA, AC plus RTMS had the highest probability of improving depressive symptoms with a probability of 49.43%. |
| Conclusions | The results of this study indicate that AC alone or combined with other therapies appears to be effective in improving depression symptoms of stroke survivors. Moreover, in comparison to WM, AC alone or plus RTMS, TCM, TCM with WM, or WM, were more effective in improving depression symptoms of PSD. Also, AC with RTMS seems to be the most effective with the highest probability. |
1.1.2. Xie 2022 (umbrella review)
Xie J, Geng X, Fan F, Fu X, He S, Li T. The efficacy of therapies for post-stroke depression in aging: An umbrella review. Front Aging Neurosci. 2022 Aug 23;14:993250. https://doi.org/10.3389/fnagi.2022.993250.
| Objective | Post-stroke depression (PSD) is a common complication after stroke. PSD is associated with emotional disorders and psychological dependence, which are potential risk factors for stroke recurrence and suicidality. This study aimed to perform an umbrella review of therapies for PSD through a comprehensive literature search. |
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| Methods | A systematic search was conducted in the PubMed and Web of Science by two independent authors. We examined the Hamilton Depression Scale (HAMD), Activities of daily living (ADL), Neurologic function as efficacy endpoints, and the incidence of adverse events as safety profiles. Seventeen eligible studies, including 267 clinical trials were included in this study. |
| Results | The results showed that High-Frequency Repetitive Transcranial Magnetic Stimulation (HfrTMS), Acupuncture/EA+conventional treatment, Escitalopram, Modified Sini San, Moxibustion, Xiaoyao Formula, Paroxetine, Chinese herbal medicine, Exercise, Citalopram, and Cognitive behavioral therapy are beneficial for improving the depression symptoms of patients with PSD. HfrTMS and Sertraline may have an impact on slowing the scores of activities of daily living or neurologic function. In addition, Acupuncture/EA+conventional, Escitalopram, Citalopram, Sertraline, and Fluoxetine showed no serious adverse events in PSD patients. |
| Conclusions | Our study demonstrated that 11 treatment methods can effectively improve the condition of PSD patients. |
1.1.3. Zhang 2022
Zhang J, Song Z, Gui C, Jiang G, Cheng W, You W, Wang Z, Chen G. Treatments to post-stroke depression, which is more effective to HAMD improvement? A network meta-analysis. Front Pharmacol. 2022 Dec 19;13:1035895. https://doi.org/10.3389/fphar.2022.1035895
| Introduction | Post-stroke depression (PSD) is a common mental health problem after cerebrovascular accidents. There are several treatments that have been shown to be effective in treating post-stroke depression. However, it is not clear which treatment is more effective. |
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| Methods | In this meta-analysis, an appropriate search strategy was used to search eligible randomized controlled trials (RCTs) on different treatments to treat patients with Post-stroke depression published up to December 2021 from the CNKI, PubMed, and Cochrane Library. We assessed the mean difference or odds ratio between each treatment and placebo and summarized them as the average and 95% confidence interval (CI) by conducting Bayesian network meta-analyses. |
| Results | By constructing a Bayesian network meta-analysis, we found that acupuncture combined with fluoxetine (vs placebo MD, -8.9; 95% CI, [-15, -2.9]) or paroxetine (vs placebo MD,-8.5; 95% CI, [-15, -2.5]) was the most effective for change in Hamilton depression scale (HAMD) at the end of the 4th week. For change in Hamilton depression scale at the end of the 8th week, rTMS combined with paroxetine (vs placebo MD, -13; 95% CI, [-17, -7.9]) had the greatest amount of change. The efficacy of medication combined with adjuvant therapy was also superior for the percentage of patients with Hamilton depression scale change over 50%. |
| Discussion | The combination of antidepressants with adjuvant therapy may enhance the efficacy of antidepressants and achieve better results than antidepressant monotherapy in both Hamilton depression scale changes at the end of week 4 or 8 and 50% Hamilton depression scale improvement rate. Acupuncture combined with fluoxetine treatment was more effective in the treatment of post-stroke depression at week 4, while rTMS combined with paroxetine was more effective at week 8. Further research is needed to determine whether acupuncture combined with fluoxetine is better than rTMS combined with paroxetine for post-stroke depression at week 8. |
1.1.4. Liu 2021
Liu R, Zhang K, Tong QY, Cui GW, Ma W, Shen WD. Acupuncture for post-stroke depression: a systematic review and meta-analysis. BMC Complement Med Ther. 2021;21(1):109. [217736]. https://doi.org/10.1186/s12906-021-03277-3
| Background | Acupuncture for post-stroke depression (PSD) has been evolving, but uncertainty remains. To assess the existing evidence from randomized clinical trials (RCTs) of acupuncture for PSD, we sought to draw conclusions by synthesizing RCTs. |
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| Methods | An exhaustive literature search was conducted in seven electronic databases from their inception dates to April 19, 2020, to identify systematic reviews (SRs) and meta-analyses (MAs) on this topic. The primary RCTs included in the SRs/MAs were identified. We also conducted a supplementary search for RCTs published from January 1, 2015, to May 12, 2020. Two reviewers extracted data separately and pooled data using RevMan 5.3 software. The quality of evidence was critically appraised with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system. |
| Results | A total of 17 RCTs involving 1402 patients were included. Meta-analysis showed that participants who received a combination of acupuncture and conventional treatments exhibited significantly lower scores on the HAM-D17, HAM-D24 and HAM-D (MD, − 5.08 [95% CI, − 6.48 to − 3.67], I2 = 0%), (MD, − 9.72 [95% CI, − 14.54 to − 4.91], I2 = 65%) and (MD, − 2.72 [95% CI, − 3.61 to − 1.82], respectively) than those who received conventional treatment. However, there was no significant difference in acupuncture versus antidepressants in terms of the 17-item, 24-item and HAM-D scales (MD, − 0.43 [95% CI, − 1.61 to 0.75], I2 = 51%), (MD, − 3.09 [95% CI, − 10.81 to 4.63], I2 = 90%) and (MD, − 1.55 [95% CI, − 4.36 to 1.26], I2 = 95%, respectively). For adverse events, acupuncture was associated with fewer adverse events than antidepressants (RR, 0.16 [95% CI, 0.07 to 0.39], I2 = 35%), but there was no significant difference in the occurrence of adverse events between the combination of acupuncture and conventional treatments versus conventional treatments (RR, 0.63 [95% CI, 0.21 to 1.83], I2 = 38%). The quality of evidence was low to very low due to the substantial heterogeneity among the included studies. |
| Conclusions | The current review indicates that acupuncture has greater effect on PSD and better safety profile than antidepressants, but high-quality evidence evaluating acupuncture for PSD is still needed. |
1.1.5. Wang 2021
Wang X, Xiong J, Yang J, Yuan T, Jiang Y, Zhou X, Liao K, Xu L. Meta-analysis of the clinical effectiveness of combined acupuncture and Western Medicine to treat post-stroke depression. Journal of TCM. 2021;41(1):6-16. [216956]. doi
| Objective | To evaluate the clinical efficacy and safety of combined acupuncture and Western Medicine in the treatment of post-stroke depression using a meta-analysis. |
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| Methods | The China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, Chinese Biomedical Literature Database, PubMed, Embase, and the Cochrane Library were searched from their establishment to August 2018 for randomized controlled trials (RCTs) of combined acupuncture and Western Medicine to treat post-stroke depression. Two researchers independently extracted and cross-checked data, and then applied the modified Jadad scale and the Cochrane-recommended assessment method to evaluate the risk of bias. Review Manager 5.3 was used to conduct the meta-analysis. |
| Results | A total of 1860 patients in 24 RCTs were analyzed. The results of the Meta-analysis showed that: (a) The effective rate of acupuncture + fluoxetine hydrochloride vs fluoxetine hydrochloride was significant [relative risk (RR) = 1.16, 95% confidence interval (CI) (1.08, 1.26)], as was that of acupuncture + flupentixol/melitracen vs flupentixol/melitracen [RR = 1.23, 95% CI (1.10, 1.37)]. (b) When analyzing Hamilton Depression Scale (HAMD)-17 scores, six trials showed that acupuncture combined with Western Medicine was superior to Western Medicine alone, and could relieve the depressive symptoms of patients. For HAMD-24 scores, five trials were included for acupuncture + fluoxetine hydrochloride vs fluoxetine hydrochloride, with significance at 2 weeks [WMD = －6.51, 95% CI(－ 8.62, － 4.40)], as well as at 4 weeks [WMD = －8.40, 95% CI (－11.86, －4.94)] and 8 weeks. ©For the activities of daily living scale, acupuncture + fluoxetine hydrochloride vs fluoxetine hydrochloride [WMD = 22.65, 95% CI (18.34, 26.95)], acupuncture + flupentixol/melitracen vs flupentixol/melitracen [WMD = 8.08, 95% CI (2.57, 13.59)], acupuncture + sertraline hydrochloride vs sertraline hydrochloride [WMD = 6.94, 95% CI (3.59, 10.29)], and acupuncture + doxepin hydrochloride vs doxepin hydrochloride [WMD = 18.80, 95% CI (15.84, 21.76)] had significance. (d) For Treatment Emergent Symptom Scale scores, there was significance in all four included studies. |
| Conclusion | The therapeutic effects of acupuncture combined with Western Medicine on post-stroke depression are often better than those of Western Medicine alone, and fewer adverse reactions occur. However, more high-quality RCTs are needed to further confirm these findings. |
1.1.6. Zhang 2021 (combined with antidepressants)
Zhang K, Cui G, Gao Y, Shen W. Does acupuncture combined with antidepressants have a better therapeutic effect on post-stroke depression? A systematic review and meta-analysis. Acupunct Med. 2021 Oct;39(5):432-440. https://doi.org/10.1177/0964528420967675
| Objective | To evaluate the effectiveness of acupuncture combined with antidepressants in the treatment of post-stroke depression (PSD). |
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| Methods | The following electronic databases were systematically searched: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Wanfang Data, China National Knowledge Infrastructure and Chongqing VIP database. The primary outcome was the Hamilton depression scale (HAMD) score. Two independent investigators screened for eligible clinical trials. The Cochrane risk of bias tool was used to assess the methodological quality, and RevMan 5.3 was applied for meta-analysis. |
| Results | Thirteen randomized controlled trials (RCTs) involving 904 participants were included in the study. The results of this meta-analysis showed that, compared with antidepressants alone, acupuncture combined with antidepressants led to a significant decrease in the HAMD score (mean difference (MD): −3.60, 95% confidence interval (CI): −4.25 to −2.95, P < 0.001), had a better effective rate (risk ratio (RR): 1.33, 95% CI 1.19 to 1.49, P < 0.001) and lower National Institutes of Health Stroke Scale (NIHSS) scores (MD: −2.39, 95% CI: −3.37 to −1.41, P < 0.001), and led to a significant increase in the Barthel index scores (MD: 8.10, 95% CI: 5.25 to 10.94; P < 0.001). |
| Conclusions | Acupuncture combined with antidepressants showed a more favourable effect on the treatment of PSD than antidepressants alone. However, given the limited methodological quality, more high-quality RCTs conducted based on the Consolidated Standards of Reporting Trials (CONSORT) and Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines are necessary. |
1.1.7. Zhang 2021 (vs antidepressant therapy)
Zhang L, Chen B, Yao Q, Chen W, Yang W, Yang W, He L, Zhang Y. Comparison between acupuncture and antidepressant therapy for the treatment of poststroke depression: Systematic review and meta-analysis. Medicine (Baltimore). 2021;100(22). [217816]. doi
| Background | In this paper, a systematic review and meta-analysis of published randomized controlled trials (RCTs) was conducted to compare the efficacies of acupuncture and antidepressant therapy for the treatment of poststroke depression (PSD). |
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| Methods | The research team searched RCTs published on PubMed; Medline; Cochrane library; Chinese National Knowledge Infrastructure (CNKI); Wanfang; Embase; Scopus, and Sinomed from their respective establishments to January 2019. We evaluated the Hamilton Depression Rating Scale (HAMD) scores, Treatment Emergent Symptom Scale (TESS) scores, National Institute of Health Stroke Scale (NIHSS) scores, and total clinical efficacy using fixed effects models. |
| Results | Fourteen RCTs, representing a total of 1124 patients, were studied.showed that acupuncture was more effective in improving HAMD scores at 3 weeks after administration (mean difference [MD] = -1.17, 95%CI = -2.18 to -0.16), at 4 weeks (MD = -4.44, 95% CI = -5.64 to -3.23), at 6 weeks (MD = -1.02, 95% CI = -1.68 to -0.36), and at 8 weeks (MD = -4.33, 95% CI = -4.96 to -3.70). Similarly, acupuncture more dramatically decreased NIHSS scores (MD = -2.31, 95% CI = -2.53 to -2.09), and TESS scores (MD = -4.70, 95% CI = -4.93 to -4.48) than conventional Western medicinal therapy. Further, the total clinical efficacy in the acupuncture group was significantly higher than in the antidepressants group (risk ratio [RR] = 1.15, 95% CI = 1.08-1.21). |
| Conclusions | The results of this study suggest that acupuncture not only can reduce the severity of PSD, but also has significant effects on decreasing the appearance of other adverse events. |
1.1.8. Huang 2018
Huang Yingjie, Li Lixia, Zhou Yalan, Wu Juan, Lin Guohua, Ming Kangwen, Zhang Qufei. [A Meta-analysis of the Efficacy of Acupuncture and Electro -acupuncture on Post-stroke Depression]. Modern Hospital Year. 2018;1:120-124. [201798].
| 目的 系统评价针刺及电针治疗对中风后抑郁症(PSD)的有效性.方法 计算机检索The Cochrane Library、PubMed、Embase、Medline、中国生物医学期刊(CBM)、维普(VIP)、中国知网(CNKI)和万方数据库,搜集使用针刺、电针、针刺结合西药或电针结合西药治疗PSD的相关随机对照试验(RCT).由2位研究者独立进行文献筛选、资料提取,并评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行Meta分析.结果 最终纳入13个RCT,共1193例患者.Meta分析结果显示:在改善中风后抑郁症患者抑郁状态方面,针刺与单纯西药治疗差异无统计学意义,森林图提示:[MD=-0.54,95％CI(-1.46,0.39),P=0.26];电针与单纯西药治疗差异无统计学意义,森林图提示:[MD=0.13,95％CI(-1.07,1.33),P=0.83];针刺结合西药明显优于单纯西药,森林图提示:[MD=-3.28,95％CI(-4.45,-2.12),P<0.00001].电针结合西药与单纯西药治疗差异无统计学意义,森林图提示:[MD=-0.39,95％CI(-8.92,2.74),P=0.3].结论 针刺及电针是一种有效的改善中风后抑郁症患者抑郁状态的治疗手段,与口服西药等措施联用,可显著提高疗效.但由于纳入本研究的RCT质量及数量有限,存在一定的偏倚风险,本研究结论尚需更多高质量的临床试验进一步验证. | |
| Objective | To systematically evaluate the effectiveness of acupuncture and electroacupuncture on post-stroke depression (PSD). |
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| Methods | Computer search The Cochrane Library, PubMed, Embase, Medline, Chinese Biomedical Journal (CBM), VIP (VIP), China Knowledge Network (CNKI) and Wanfang database, collecting randomized controlled trials (RCT) for the treatment of PSD using acupuncture, electroacupuncture, acupuncture combined with western medicine or electroacupuncture combined with western medicine. Two researchers independently conducted literature screening, data extraction, and After evaluating the risk of bias in the included study, Meta-analysis was performed using RevMan 5.3 software. |
| Results | The results were finally included in 13 RCTs with a total of 1193 patients. The results of the meta-analysis showed that acupuncture and western medicine were used to improve the depression status of patients with post-stroke depression. The difference was not statistically significant. The forest map suggested: [MD=-0.54, 95% CI (-1.46, 0.39), P=0.26]; there was no significant difference between electroacupuncture and western medicine treatment. The forest map suggested: [MD= 0.13, 95% CI (-1.07, 1.33), P=0.83]; acupuncture combined with western medicine is significantly better than western medicine alone, forest map suggestion: [MD=-3.28, 95% CI (-4.45, -2.12), P< 0.00001]. There is no statistically significant difference between electroacupuncture combined with western medicine and simple western medicine. The forest map suggests: [MD=-0. 39, 95% CI (-8.92, 2.74), P = 0.3]. |
| Conclusion | Acupuncture and electroacupuncture are effective treatments for improving depression in patients with post-stroke depression, and can be used in combination with oral western medicine. Improve the efficacy. However, due to the limited quality and quantity of RCT included in this study, there is a certain risk of bias. The conclusion of this study needs more high-quality clinical trials to further verify. |
1.1.9. Zhou 2018
Zhou Xin, Ren Lu, Gao Yuanyuan, Wu Weining. [Meta Analysis of Effect of Acupuncture and Antidepressants on Depression in Patients with Post-Stroke Depression]. Chinese Archives of Traditional Chinese Medicine Year. 2018;12:2875-2879. [201757].
| Objective | To evaluate the clinical therapeutic effect of acupuncture in the treatment of post-stroke depression. |
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| Methods | We retrieved CNKI, VIP, Wanfang database, PubMed and Cochrane Library by computer. Randomize controlled trials of acupuncture for treatment of post-stroke depression collection(RCT)were collected. We evaluated the quality of the included studies according to the evaluation of Cochrane risk bias assessment tool. And then we carried out Meta-analysis using RevMan 5.3 software. |
| Results | A total of 19 randomized controlled trials with 1376 cases of patients with post-stroke depression were included. The Meta-analysis results:(1) HAMD scores changes before and after treatment showed that acupuncture treatment was better than antidepressant in the control group in improving the depressive state of PSD patients and reducing the reuptake of 5-HT in serum.(2)The acupuncture therapy was not clear in improving the neurological deficit of PSD patients. The change of HAMD scale scores before and after treatment indicated that the difference between acupuncture treatment group and antidepressant drug control group was statistically significant. |
| Conclusion | In the clinical treatment of post-stroke depression, acupuncture treatment is better than antidepressant treatment. Acupuncture therapy is safe and effective, with less adverse reactions. However, the conclusion between the subgroups is not clear, and more high-quality randomized controlled trials are needed to further validate the efficacy. |
1.1.10. Zhang 2017
Zhang Dan, Zhang Chunhong, Ma Huijing. [A Systematic Review of the Efficacy of Chinese Therapy on Preventing Post-stroke Depression]. Journal of Emergency in Traditional Chinese Medicine. 2017;04. [52334].
| Objective | To systematically review the efficacy of traditional Chinese medicine therapy in the prevention of post-stroke depression (PSD). |
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| Methods | CNKI, VIP database, Wan Fang database, Pub Med, MEDLINE were searched by the key words acupuncture, traditional Chinese medicine, prevention, brain stroke, stroke, post stroke depression in both Chinese and English by two researchers to collect higher quality randomized controlled trails (RCTS) and quasi-randomized controlled trails (CCTS) about traditional Chinese medicine therapy in the prevention of post-stroke depression. Two reviewers used Rev Man5. 3 software to do the meta-analysis after a strict screening and elimination. |
| Results | A total of 8 documents involving 1065 studies were studied by meta-analysis and the results showed that TCM therapy group compared with control group, could effectively prevent the happening of depression after stroke, OR=0. 38, 95%CI [0. 28, 0. 51] (P < 0. 00001). |
| Conclusion | The therapy of traditional Chinese medicine is effective in the prevention of post-stroke depression (PSD). But we still need more high quality studies to verify the conclusion due to small amounts of studies this time. |
1.1.11. Zhang 2014 ☆☆
Zhang J, Chen J, Chen J, Li X, Lai X, Zhang S, Wang S. Early filiform needle acupuncture for poststroke depression: a meta-analysis of 17 randomized controlled clinical trials. Neural Regen Res. 2014; 9(7):773-84. [165595].
| Objectives | To evaluate the effectiveness and safety of filiform needle acupuncture for poststroke depression, and to compare acupuncture with the therapeutic efficacy of antidepressant drugs. |
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| Methods | We retrieved data from the Chinese National Knowledge Infrastructure (1979-2012), Wanfang (1980-2012), VIP (1989-2012), Chinese Biomedical Literature (1975-2012), PubMed (1966-2012), Ovid Lww (-2012), and Cochrane Library (-2012) Database using the internet. SELECTION CRITERIA: Randomized controlled trials on filiform needle acupuncture versus antidepressant drugs for treatment of poststroke depression were included. Moreover, the included articles scored at least 4 points on the Jadad scale. EXCLUSION CRITERIA: other acupuncture therapies as treatment group, not stroke-induced depression patients, score < 4 points, non-randomized controlled trials, or animal trials. MAIN OUTCOME MEASURES: These were the Hamilton Depression Scale scores, clinical effective rate, Self-Rating Depression Scale scores, Side Effect Rating Scale scores, and incidence of adverse reaction and events. |
| Results | A total of 17 randomized controlled clinical trials were included. Meta-analysis results displayed that after 4 weeks of treatment, clinical effective rate was better in patients treated with filiform needle acupuncture than those treated with simple antidepressant drugs [relative risk = 1.11, 95% confidence interval (CI): 1.03-1.21, P = 0.01]. At 6 weeks, clinical effective rate was similar between filiform needle acupuncture and antidepressant drug groups. At 2 weeks after filiform needle acupuncture, Hamilton Depression Scale (17 items) scores were lower than in the antidepressant drug group (mean difference = -2.34, 95%CI: -3.46 to -1.22, P < 0.000,1). At 4 weeks, Hamilton Depression Scale (24 items) scores were similar between filiform needle acupuncture and antidepressant drug groups. Self-Rating Depression Scale scores were lower in filiform needle acupuncture group than in the antidepressant drug group. Side Effect Rating Scale was used in only two articles, and no meta-analysis was conducted. Safety evaluation of the 17 articles showed that gastrointestinal tract reactions such as nausea and vomiting were very common in the antidepressant drug group. Incidence of adverse reaction and events was very low in the filiform needle acupuncture group. |
| Conclusions | Early filiform needle acupuncture for poststroke depression can perfectly control depression. Filiform needle acupuncture is safe and reliable. Therapeutic effects of filiform needle acupuncture were better than those of antidepressant drugs. |
1.1.12. Zhang 2014 ☆
Zhang Wei, Sun Jian-Hua, Gao Yang, Pei Li-Xia, Wu Xiao-Liang, Chen Lu et al. System review on treating post-stroke depression with acupuncture. World Journal of Acupuncture- Moxibustion 2014.24(2):52. [176422].
| Objective | To assess the efficacy and safety of treating post-stroke depression with acupuncture compared to western medicine systematically. |
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| Methods | Databases were retrieved such as Cochrane Library, PubMed, Web of Sicence, Embase, CBM, CNKI and WanFang Data so as to look up randomized controlled trials (RCT) of treating post-stroke depression with acupuncture and western medicine, and the time limit for the retrieval spanned from the date of database established to September 2013. By extracting data and evaluating methodological quality of included studies according to inclusion and exclusion criteria, RevMan 5.2 software was applied for Meta-analysis and evidence quality was assessed by adopting the GRADE system. |
| Results | A total of 13 RCTs (845 patients with post-stroke depression) were included in this study. It was revealed by Meta-analysis that the differences of the two groups were statistically significant in terms of HAMD scale scores measured at the end of the treatment by comparing the treatment of acupuncture and western medicine [SMD=0.26, 95% CI (0.11, 0.40)], but via susceptibility analysis (excluding low quality studies), the differences were not statistically significant [SMD=-0.06, 95% CI (-0.37, 0.25)], and the reliability of the results was low; in terms of adverse events, the differences were statistically significant [RR=0.32, 95% CI (0.19, 0.53)], and the risk of adverse events reduced by 68% in the acupuncture group. From the assessment on evidence quality grade based on GRADE system, it was revealed that HAMD scores and adverse events were evidences with fairly low quality. |
| Conclusion | Although this system assessment showed that treating post-stroke depression with acupuncture was more effective compared with western medicine, the result was less reliable and quality of evidences was poor. The above-mentioned results need more highquality randomized controlled trials for further verification. |
1.1.13. Zhang 2012
Zhang GC, Fu WB, Xu NG, Liu JH, Zhu XP, Liang ZH, Huang YF, Chen YF. Meta analysis of the curative effect of acupuncture on post-stroke depression. J Tradit Chin Med. 2012;32(1):6-11. [164843].
| Objectives | To systematically evaluate the curative effect of acupuncture on post-stroke depression (PSD). |
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| Methods | The internet was used to retrieve the Wanfang Medical Data System, Chinese Periodical Net, the Weipu Information Resources System, PubMed and the Cochrane Library Database. Relevant articles, up to September 2010, were manually retrieved. These papers included studies that had performed random and semi-random control trials for the use of acupuncture to treat PSD. Fifteen random control tests involving 1096 patients were included in this study and individual cases, interventional measures and curative effects were extracted from this research. Grade methodological quality evaluation and meta-analysis were performed on these studies. |
| Results | Comparison between the acupuncture group and the Western medicine group for the curative rate on PSD revealed an OR of 1.48, 95% CI = [1.11 1.97] and P = 0.008. Comparison of obviously effective rate shows that OR = 1.39, 95% CI = [1.08 1.80] and P = 0.01. Comparison of effective rate shows that OR = 0.83, 95% CI = [0.631.09] and P = 0.18. |
| Conclusions | Comparison between the acupuncture group and Western medicine group in treating PSD revealed that there is a statistical difference in curative rate and remarkably effective rate, but no difference in effective rate. |
1.1.14. Zhang 2010 ☆☆
Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis, J Affect Disord. 2009. 124(1-2):9-21. [136615].
| Background | Although acupuncture has been used as an alternative treatment for depressive disorders, its effectiveness and safety are not well defined. The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of acupuncture as monotherapy and as an additional therapy in treating various depressive conditions, particularly major depressive disorder (MDD) and post-stroke depression (PSD). |
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| Methods | Following systematic review, meta-analysis was conducted on high-quality randomized controlled trials (RCTs). |
| Results | Of 207 clinical studies of acupuncture for various depression retrieved, 113 (54.6%) were on MDD and 76 (36.7%) on PSD. Twenty RCTs of MDD (n=1998) and 15 of PSD (n=1680) identified for high-quality protocol (Jadad score >/=3) were included for meta-analysis. The efficacy of acupuncture as monotherapy was comparable to antidepressants alone in improving clinical response and alleviating symptom severity of MDD, but not different from sham acupuncture. No sufficient evidence favored the expectation that acupuncture combined with antidepressants could yield better outcomes than antidepressants alone in treating MDD. Acupuncture was superior to antidepressants and waitlist controls in improving both response and symptom severity of PSD. The incidence of adverse events in acupuncture intervention was significantly lower than antidepressants. |
| Conclusions | Acupuncture therapy is safe and effective in treating MDD and PSD, and could be considered an alternative option for the two disorders. The efficacy in other forms of depression remains to be further determined. |
1.1.15. Zhang 2009 ☆
Zhang JB, Ren L, Sun Y. [Meta-analysis on acupuncture for treatment of depression in patients of poststroke]. Chinese Acupuncture and Moxibustion. 2009. 29(7):599-602. [154691].
| Objective | To assess therapeutic effect and the safety of acupuncture for treatment of the depression in patients of poststroke. |
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| Methods | The clinical research documents in recent 10 years of acupuncture for treatment of depression in patients of poststroke were retrieved, the homogeneity test was used and the effect amount was complicated in the clinical randomized controlled trials (RCT) documents which had been adopted in the Meta-analysis, and furthermore the Meta-analysis was used in the Hamilton Depression Scale (HAMD) score of both acupuncture group and medication group after treatment. |
| Results | Seventeen RCT heterogeneity test results which were adopted in the study indicated that chi2 = 21.98, P = 0.14, proved that they had homogeneity, and fixed effect model was adopted to analyse, after combination, OR = 2.54, 95% confidence interval was (1.91, 3.38), according to Z test, Z = 6.41, P < 0.00001, the diamond was in the right side of the vertical line, indicated that there was a significant difference in the therapeutic effect between the acupuncture group and the medication group. The evaluation of the influence of acupuncture on HAMD indicated that there was a significant difference between the acupuncture group and the medication group. |
| Conclusion | The therapeutic effect of acupuncture for treatment of the depression in patients of poststroke is superior to other common medicine with safety, but it still needs more large sample RCTs to verify. |
1.2. Special Acupuncture Techniques
1.2.1. Electro-acupuncture
1.2.1.1. Wang 2021
Wang X, Cai W, Wang Y, Huang S, Zhang Q, Wang F. Is Electroacupuncture an Effective and Safe Treatment for Poststroke Depression? An Updated Systematic Review and Meta-Analysis. Biomed Res Int. 2021. [222765]. https://doi.org/10.1155/2021/8661162
| Objective | To observe and compare the efficacy and safety of electroacupuncture and antidepressants in the treatment of poststroke depression (PSD) using a meta-analysis method. |
|---|---|
| Methods | The VIP, CNKI, Wanfang, CMB, Embase, PubMed, and Cochrane databases were searched. All randomized controlled trials (RCT) on electroacupuncture treatment of PSD were searched and further screened. Meta-analysis was performed on electroacupuncture and western medicine for PSD to explore the difference in efficacy between electroacupuncture and western medicine for PSD. |
| Results | Nineteen RCTs were included in the meta-analysis. Compared with the Western medicine group, the meta-analysis showed no significant changes in Hamilton Depression Scale (HAMD) scores between the electroacupuncture group and the antidepressant group (P > 0.05). The number of adverse events in the electroacupuncture group was less than that in the antidepressant group. |
| Conclusion | Compared with antidepressants, electroacupuncture is not less effective in improving depression symptoms in PSD patients with greater safety. |
1.2.1.2. Li 2018
Li XB , Wang J , Xu AD , Huang JM , Meng LQ , Huang RY , Xu J. Clinical effects and safety of electroacupuncture for the treatment of post-stroke depression: a systematic review and meta-analysis of randomised controlled trials. Acupuncture in Medicine. 2018;36(5):284-293. [200331].
| Objective | The aim of this systematic review was to assess the efficacy/effectiveness and safety of electroacupuncture (EA) in the treatment of post-stroke depression (PSD). |
|---|---|
| Methods | A comprehensive literature search in the Pubmed, Embase, CENTRAL, ISI Web of Science, CNKI and Wanfang databases was conducted, and all relevant randomised controlled trials (RCTs) were screened for eligibility by two independent reviewers. The Cochrane Collaboration's tool and Jadad score were used to assess the risk of bias of included studies, and only RCTs scoring ≥3 were included in a meta-analysis. |
| Results | 18 RCTs involving a total of 813 participants (mean age 61.6 years) in the EA groups and 723 participants (mean age 61.9 years) in the control groups were included. The included studies had an average 3-point Jadad score. PSD was diagnosed according to the Chinese Classification of Cerebrovascular Disease (CCCD) and the Chinese Classification of Mental Disease (CCMD) criteria. There was no significant difference between EA and antidepressants (fluoxetine 10-40 mg/day, citalopram 20 mg/day, sertraline 50 mg/day) in terms of the Hamilton Depression Rating Scale (HAMD) scores at week 4 after treatment (standardised mean difference (SMD) -0.11, 95% CI -0.31 to 0.10), at week 6 after treatment (SMD 0.04, 95% CI -0.43 to 0.51) or at week 8 after treatment (SMD -0.01, 95% CI -0.23 to 0.22). However, the combined incidence of adverse events in the EA groups was significantly lower than in the antidepressant groups (RR 0.21, 95% CI 0.14 to 0.33). |
| Conclusion | There was no significant difference between EA and antidepressants in the severity of depression, however EA caused fewer adverse events than antidepressants. Additional larger scale RCTs with rigorous study design are required. |
1.2.2. Moxibustion
1.2.2.1. Guo 2022
Guo SQ, Zhao GZ, Li ST, Yao Q, Han L, Li B, Wang H, Liu YJ, Zhao BX. Moxibustion for treating patients with post-stroke depression: a systematic review and meta-analysis. Ann Palliat Med. 2022 Jan;11(1):85-97. https://doi.org/10.21037/apm-21-3421
| Background | To assess the effectiveness and safety of moxibustion for post-stroke depression (PSD). |
|---|---|
| Methods | A search was conducted in the following English and Chinese databases: Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature (CBM), VIP and Wanfang. The outcomes included Hamilton Depression Rating Scale (HAMD), effective rate, and Modified Edinburgh-Scandinavian Stroke Scale (MESSS) scale. The formulation of search strategy, data extraction, and quality evaluation of involved studies was performed according to Cochrane handbook guidelines. The software RevMan 5.4 and Stata 16 were used for data analysis. The evidence quality of each outcome was evaluated by GRADEpro guideline development tool (GDT). |
| Results | A total of 14 trials with 863 participants were included. A certain risk of bias of unclear or high was detected in the included studies. Compared with the control group, adding moxibustion could change the value of HAMD [standardized mean difference (SMD) =-1.17; 95% confidence interval (CI): -1.55 to -0.79; I2=85.5%; P<0.01] and the effective rate [risk ratio (RR) =1.22; 95% CI: 1.13 to 1.32; I2=0.0%; P=0.56], and the differences in the MESSS scale (SMD =-0.72; 95% CI: -1.06 to -0.38; I2=0.0%; P=0.80) had statistical differences. The certainty was low in effective rate, and very low in HAMD and MESSS. Besides, moxibustion was shown to be generally safe. |
| Discussion | This review found that moxibustion may be an effective intervention for PSD. However, the results of this study have a certain limitation. The benefits of moxibustion for PSD need to be confirmed in the future by more high-quality randomized controlled trials (RCTs). |
1.2.2.2. Lu 2013 ☆
Lu Xiao-Lin, Sun Zhong-Ren, Zhang Qin-Hong, Du Wei. [Systematic review of clinical moxibustion treatment for post-stroke depression]. Shanghai Journal of Acupuncture and Moxibustion 2013.32(11):954. [178908]
| Objective | To evaluate the clinical efficacy of moxibustion in treating post-stroke depression. |
|---|---|
| Methods | Searches of CNKI, Wanfang, VIP and PubMed databases retrieved 157 pieces of literature. Finally, 5 pieces of literature met the inclusion criteria and were qualitatively assessed using CLEAR NPT. |
| Results | Analysis of 5 included pieces of literature showed that moxibustion therapy had a definite effect on post-stroke depression with higher safety margin. |
1.2.3. Abdominal Acupuncture
1.2.3.1. Su 2021
Su IJ, Liao L, Huang F. A Meta-Analysis of the Effect of Abdominal Acupuncture on Post-Stroke Depression. Medical Acupuncture. 2021;33(4):269-277. [221442]. https://doi.org/10.1089/acu.2021.0001
| Objective | China has the highest stroke incidence in the world, with a large percentage of post-stroke depression (PSD). Abdominal acupuncture is used frequently to treat PSD. This research systematically evaluated the clinical efficacy of this treatment for PSD. |
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| Methods | A literature search retrieved randomized controlled trials in English and Chinese on abdominal acupuncture in conjunction with other therapies (experimental groups), compared to conventional therapies (control groups) for treating PSD from January 2000 to November 2020. Literature quality was evaluated with the Cochrane Library bias-risk assessment tool. RevMan5.3 software was used for the meta-analysis. |
| Results | A total of 10 RCTs involving 708 patients were evaluated. Hamilton Depression Scale scores of the experimental groups were significantly lower than in the control groups (mean difference [MD] = -2.34; 95% confidence interval [CI]: -2.89, -1.78; P < 0.00001). Total effective rates of the experimental groups were significantly higher than in the control groups (odds ratio = 3.90; 95% CI: 2.29, 6.62, P < 0.00001). Barthel index scores in the experimental groups were significantly higher than in the control groups (MD = -11.39; 95% CI: 9.07, 13.72; P < 0.00001). There were no significant differences in National Institutes of Health Stroke Scale (NIHSS) scores between the 2 groups (MD = -0.03; 95% CI: -0.68, 0.62; P = 0.93). |
| Conclusions | Abdominal acupuncture for treating PSD is generally effective. However, the degree of neurologic improvement needs further investigation. |
1.2.4. Ocular Acupuncture
1.2.4.1. Yang 2019
Yang Wei, Wang Pengqin. [Systematic Review and Meta-Analysis of the Clinical Efficacy of Eye Acupuncture in the Treatment of Poststroke Depression]. Journal of Practical Traditional Chinese Internal Medicine. 2019;4:1-5+77. [201713].
| Background | ocular acupuncture is effective in treating apoplexy sequelae. |
|---|---|
| Objective | To systematically evaluate the clinical study of eye acupuncture in the treatment of post-stroke depression, and to explore the effectiveness of eye acupuncture in the treatment of post-stroke depression. |
| Methods | [Retrieval strategies] The databases of CNKI, Wanfang, VIP, CBM, PubMed and Cochrane library were comprehensively searched. The retrieval time is from the establishment of the database to December 2018. [Inclusion criteria]research design :① a randomized controlled trial(RCT)of eye acupuncture for the treatment of poststroke depression. ② object of observation: poststroke depression was clearly diagnosed, meeting the criteria for the diagnosis and evaluation of therapeutic effect of stroke or the diagnostic essentials of various cerebrovascular diseases and the diagnostic criteria for depression syndrome in 1995. ③ intervention measures: the treatment group used eye acupuncture therapy or eye acupuncture with other therapies, the control group used noneye acupuncture therapy.④ outcome index: effective rate, HAMD, SDS, ADL, SSS, TCM syndrome effect evaluation scale. [Data collection and analysis] The retrieved literatures were imported into NoteExpress software for preliminary screening, and then two researchers independently screened and identified the literatures according to the admission criteria. In case of any disagreement, a third party was invited to arbitrate. Data extraction table was used, and the extraction contents included: baseline condition, intervention measures, effective rate, Hamilton depression scale(HAMD), self-rating depression scale(SDS), etc… |
| Main results | A total of 59 references were obtained through screening, 31 duplicates were deleted, reading excerpts and original texts were deleted, 1 animal experiment, 8 research progress articles, 8 non-post-stroke depression related diseases articles, 2 clinical studies that did not meet the exclusion criteria were excluded, and 9 articles were finally included. Meta analysis results showed that the total effective rate RR=1.22 [1.12,1.33], P=0.68>0.05. HAMD MD=3.22 [3.04, 3.39]; SDS score MD=3.73 [3.63, 3.83]. |
| Questions and prospects | Eye acupuncture combined with medicine or body acupuncture is superior to non-eye acupuncture in the treatment of post-stroke depression. However, the total sample size is relatively small, and the evidence for efficacy is insufficient. The quality of included literature methodological studies is not high, and more high-quality clinical studies are expected to improve the evidence intensity. |
1.2.5. Comparison of acupuncture techniques
1.2.5.1. Hang 2021
Hang X, Li J, Zhang Y, Li Z, Zhang Y, Ye X, Tang Q, Sun W. Efficacy of frequently-used acupuncture methods for specific parts and conventional pharmaceutical interventions in treating post-stroke depression patients: A network meta-analysis. Complement Ther Clin Pract. 2021 Nov;45:101471. https://doi.org/10.1016/j.ctcp.2021.101471.
2. Overviews of Systematic Reviews
2.1. Hung 2019
Hung CY, Wu XY, Chung VC, Tang EC, Wu JC, Lau AY. Overview of systematic reviews with meta-analyses on acupuncture in post-stroke cognitive impairment and depression management. Integr Med Res. 2019;8(3):145-159. [199813].
| Background | Acupuncture has been using as an alternative non-pharmacological therapy in the management of post stroke depression and cognitive impairment but its effectiveness and safety remain controversial. We conducted an overview of systematic reviews with meta-analyses to evaluate the evidence on the effect of acupuncture in the treatment of stroke with conventional medicine intervention. |
|---|---|
| Methods | Systematic reviews summarized the treatment effects of acupuncture for post stroke cognitive impairment and post stroke depression were considered eligible. Methodological quality of included systematic reviews was assessed using A Measurement Tool to Assess systematic Reviews 2 (AMSTAR 2). |
| Results | Four systematic reviews on post stroke cognitive impairment and ten systematic reviews on post stroke depression with good methodological quality were included. Meta-analyses revealed that acupuncture plus cognitive rehabilitation; and acupuncture or moxibustion plus cognitive rehabilitation, versus cognitive rehabilitation demonstrated statistically significant increase in Mini-Mental State Examination scores in compared to cognitive rehabilitation after 4 weeks treatment [Pooled weighted mean difference (WMD) = 3.14, 95% confidence interval (CI) = 2.06 to 4.21, I2 = 36%]; and (Pooled WMD = 3.22, 95% CI = 2.09 to 4.34, I2 = 0%). Furthermore, acupuncture versus antidepressant demonstrated statistically significant improve depression measured by increasing in 17-item Hamilton Depression Rating Scale in comparing to cognitive rehabilitation after 2 weeks treatment (Pooled WMD= -2.34, 95% CI= -3.46 to -1.22, I2 = 5%). Acupuncture usage was not associated with increased risk of adverse events. |
| Conclusions | Acupuncture is safe and improves cognitive function and depressive disorder without obvious serious adverse events for post stroke patients. |
3. Clinical Practice Guidelines
| ⊕ positive recommendation (regardless of the level of evidence reported) Ø negative recommendation, (or lack of evidence) |
3.1. Stroke Foundation (Australia, New-Zealand) 2022 ⊕
Australian and New Zealand Clinical Guidelines for Stroke Management - Chapter 6: Managing complications. https://app.magicapp.org/#/guideline/WE8wOn
| For stroke survivors with depression or depressive symptoms, acupuncture may be used. (Zhang et al 2010) [Weak recommendation]. |
3.2. Japan Stroke Society (JSS, Japan) 2021 ⊕
The Japan Stroke Society. [Japanese Guidelines for the Management of Stroke, 2021] . Kyowa Kikaku Co. Ltd.; 2021 [in Japanese] . Cited by Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res. 2022 Sep;11(3):100838. https://doi.org/10.1016/j.imr.2022.100838
| Acupuncture. May be considered for post stroke depression. |
3.3. Canadian Partnership for Stroke Recovery (CPSR, Canada) 2018 ⊕
Evidence-based review of stroke rehabilitation: 18th edition, Canadian Partnership for Stroke Recovery (CPSR). 2018. [197578]. URL/
| Post Stroke Depression and Mood Disorders. There is Level 1b evidence that a combination of acupuncture and herbal medicine reduces depressive symptoms post stroke when compared to standard care. There is Level 1b evidence that acupuncture is no more effective than sham acupuncture in reducing depressive symptoms post stroke. There is Level 1b evidence that dense cranial acupuncture reduces post-stroke depressive symptoms in the short term when compared to non-invasive cranial acupuncture. There is Level 1b and Level 2 evidence that acupuncture reduces post-stroke depressive symptoms in the short term when compared to antidepressants. There is Level 2 and Level 4 evidence that electroacupuncture reduces depressive symptoms post stroke. There is limited Level 2 evidence that meridian acupressure reduces depressive symptoms post stroke when compared to standard care. |
