Schizophrenia
Schizophrénie
| ☆☆☆ | 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. Huang 2023
Huang C, Zhang P, Dong Y, Chang R, Lao J, Li Z, Lan D. A Meta-Analysis on the Efficacy of Acupuncture as an Adjuvant Therapy for Schizophrenia. Neuropsychiatr Dis Treat. 2023 Nov 7;19:2381-2400. https://doi.org/10.2147/NDT.S428518
| Objective | To systematically evaluate the efficacy of acupuncture in the treatment of schizophrenia. |
| Methods | We searched China National Knowledge Infrastructure (CNKI), Wanfang Database, Chongqing VIP Chinese Science and Technology Periodical Database (VIP), China Biology Medicine Database (CBM), PubMed, Embase, Web of Science, Cochrane Library for relevant literature on the acupuncture treatment of schizophrenia published from database inception to May 17, 2023. The evaluation criteria included total effective rate, incidence of adverse reactions, TESS scale, PANSS scale, BPRS scale, SANA scale, SAPS scale. Two researchers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. The RevMan 5.4 software was used for meta-analysis, risk of bias (ROB) evaluation tool was used to evaluate the risk of bias of the studies, and the GRADE evaluation tool was used to evaluate the quality of evidence. The study was registered on PROSPERO, CRD42023416438. |
| Results | A total of 38 RCTs involving 3143 patients were included in the meta-analysis. The results showed that acupuncture can improve the total effective rate [OR=3.43 (95% CI: 2.71, 4.35), moderate credibility], reduce the incidence of adverse reactions [OR=0.45 (95% CI: 0.32, 0.63), moderate credibility], reduce the TESS score (side effect scale) [MD=-1.83 (95% CI: -2.94, -0.71), very low credibility]. Acupuncture also reduced the PANSS total score [MD=-5.75 (95% CI: -8.08, -3.42), very low credibility], SANA score [MD=-2.66 (95% CI: -6.84, 1.51), very low credibility], SAPS score [MD=-1.26 (95% CI: -2.55, -0.02), very low credibility], and BPRS score [MD=-7.02 (95% CI: -10.59, -3.46), very low credibility]. |
| Conclusion | Existing evidence indicates that acupuncture as an adjunctive therapy can improve the total effective rate of SZ patients, reduce the incidence of adverse reactions, improve clinical symptoms, and alleviate depression and anxiety in SZ patients. However, more high-quality clinical research evidence is still needed to support these findings. |
1.1.2. Zhang 2019
Zhang Wenzhong, Hu Qiongyue. [Meta-Analysis of Acupuncture and Moxibustion in the Treatment of Schizophrenia]. China Reflexology Journal (双足与保健). 2019;6:27-28. [201724].
| Objective | To evaluate the effect of acupuncture and moxibustion on positive classification of mental disorders. |
| Methods | Literature related to acupuncture and moxibustion for the treatment of schizophrenia was searched from all aspects in major medical literature databases at home and abroad. Research literature was included according to the principles and means of evidence-based medicine, and meta-analysis was performed. |
| Results | After comprehensive screening, it was found that 17 literatures were finally selected. Meta-analysis results:(1)in terms of total effective rate, heterogeneity test of literature research results: Chi=14.26, freedom is 16, P=0.58,12= 0%. It was considered that the studies were qualitative. When the combined OR value is 3.09, the 95% confidence interval is [2.31,4.13], and the combined effect test Z=7.62, P<0.000 01. The diamond lies to the right of the line. In terms of adverse reactions, the binary variable study showed that the OR value after combination was 0.34, and the 95% confidence interval was [0.16,0.75]. The combined effect test z=2.67, P=0.008. The diamond is to the left of the line. For continuous variables, the combined SMD value was-0.91, and the 95% confidence interval was [-0.88,-0.34]. The combined effect test z=4.39,P<0.000 1. |
| Conclusion | According to the existing research data at home and abroad, the therapeutic effect of acupuncture combined with conventional antipsychotic drugs in the treatment of schizophrenia is significantly lower than that of antipsychotic drugs alone, and the incidence of adverse reactions is also significantly lower. Rigorous and careful experimental design is still required. High-quality clinical studies with large sample size provide more reliable basis for the following analysis. |
1.1.3. van den Noort 2018
van den Noort M, Yeo S, Lim S, Lee SH, Staudte H, Bosch P. Acupuncture as Add-On Treatment of the Positive, Negative, and Cognitive Symptoms of Patients with Schizophrenia: A Systematic Review. Medicines (Basel). 2018;5(2). [113151]. doi
| Background | Schizophrenia is a severe psychiatric disorder that has a large impact on patients' lives. In addition to Western medicine, the use of additional treatments, such as acupuncture, in treating the positive, negative, and cognitive symptoms is increasing. |
| Methods | We conducted a systematic review on the use of acupuncture as an add-on treatment for patients with schizophrenia that are in regular care, with a special focus on the treatment of the often accompanying sleep disorders. In this study, we searched the Medline, ScienceDirect, Cochrane Library, Scopus, and ERIC databases with a cut-off date of 31 December 2017, thereby following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. |
| Results | Our search resulted in 26 eligible studies with 1181 patients with schizophrenia who received acupuncture treatment. Most studies showed limited evidence for the use of acupuncture as add-on therapy in the treatment of the positive, negative, and cognitive symptoms, but beneficial effects have been reported in the treatment of the accompanying sleep disorders. |
| Conclusions | Limited evidence was found for the use of acupuncture as add-on therapy in the treatment of patients with schizophrenia; however, positive results were found in the treatment of sleep disorders, but this result needs to be confirmed in large, randomized, controlled trials. |
1.1.4. Zhao 2018 ☆
Zhao JQ, Ma TM. [A Meta-analysis on Acupuncture and Moxibustion Treatment of Schizophrenia]. Acupuncture Research. 2018;43(12):806-12. [196827].
| Objective | To evaluate the clinical efficacy and security of acupuncture therapy combined with conventional antipsychotics in the treatment of schizophrenia. |
| Methods | We first comprehensively retrieved papers about acupuncture or moxibustion treatment of schizophrenia published from the time of establishment of the database to April of 2017 in Chinese databases such as Chinese National Knowledge Infrastructure(CNKI), Chinese Science and Technology Periodical Database (VIP), Wanfang, and Chinese BioMedical Literature (CBM) by using keywords “acupuncture”“moxibustion”“acupuncture ＋moxibustion”“acupuncture ＋medication”“electroacupuncture”“filiform needle”“scalp-acupuncture”“auricular acupuncture”， etc. Then, according to the principles and methods of evidence-based medicine, papers conformed to the included standards were enrolled to Meta-analysis by using Review Manager 5.3 software. |
| Results | A total of 618 studies were identified, with only 17 articles (containing 1542 patients) conformed to our included standards and analyzed finally. In regard to the total effective rate of acupuncture or moxibustion for schizophrenia, the combined OR＝3.09, 95% CI (2.31, 4.13), the diamond was on the right side of the vertical line (suggesting being effective), OR checked by Z test (Z＝7.61, P<0.000 01). In regard to the untoward effect, the combined OR＝0.34, 95% CI (0.16, 0.75), the diamond was on the left side of the vertical line (suggesting less adverse effects), OR checked by Z test (Z＝2.67，P＝0.008). Sensitivity analysis: the combined standardized mean difference (SMD)＝－0.61, 95% CI(－0.88, －0.34), the diamond was on the left side of the vertical line (suggesting having more profits than simple medication), SMD checked by Z test (Z＝4.39, P<0.000 1) |
| Conclusion | Acupuncture and moxibustion combined with conventional antipsychotics is significantly better than that of antipsychotics alone in the treatment of schizophrenia and has less side effects. But, high quality clinical studies with rigorous experimental design and large sample size are needed to provide more reliable evidence. |
1.1.5. Bosch 2015 ☆
Bosch P, Van den Noort M, Staudte H, Lim S. Schizophrenia and Depression: A systematic Review of the Effectiveness and the Working Mechanisms Behind Acupuncture. Explore (NY). 2015;11(4):281-91. [186609].
| Objectives | This systematic review assessed clinical evidence for the use of acupuncture as an add-on treatment in patients with depression and schizophrenia and for its underlying working mechanisms. |
| Methods | DATA SOURCES: Four databases (Medline, Scopus, ERIC, and the Cochrane Library) were searched with a cutoff date of March 31, 2014. STUDY SELECTION: Systematic reviews and meta-analyses of acupuncture treatment for depression and schizophrenia were considered for inclusion. The scarcity of acupuncture research involving schizophrenia led to the inclusion of randomized controlled trials and case studies. DATA EXTRACTION: The primary and secondary aims of this study were to evaluate the effects of acupuncture in treating patients with depression, or schizophrenia and the possible working mechanisms underlying acupuncture through a systematic literature review. |
| Results | The overall clinical results on using acupuncture to treat depression are promising, but only limited evidence for its effectiveness in treating schizophrenia was found. Acupuncture improves the quality of life, particularly that of sleep, in psychiatric patients. Brain research has revealed that acupuncture has a modulating and normalizing effect on the limbic-paralimbic-neocortical network (LPNN), including the default mode network. Because the LPNN is related to sleep and emotions, this might explain the improved qualities of life and sleep after acupuncture. |
| Conclusions | From the evidence found in this study, acupuncture seems to be an effective add-on treatment in patients with depression and, to a lesser degree, in patients with schizophrenia, but large well-designed studies are needed to confirm that evidence. |
1.1.6. Shen 2014 ☆
Shen X, Xia J, Adams Ce. Acupuncture for schizophrenia. Cochrane Database Syst Rev. 2014. [177426]. Version résumée dans Shen X, Xia J, Adams C. Acupuncture for schizophrenia. Schizophr Bull. 2014;40(6):1198-9. [117447].
| Background | Acupuncture, with many categories such as traditional acupuncture, electroacupuncture, laser acupuncture, and acupoint injection, has been shown to be relatively safe with few adverse effects. It is accessible and inexpensive, at least in China, and is likely to be widely used there for psychotic symptoms. |
| Objectives | To review the effects of acupuncture, alone or in combination treatments compared with placebo (or no treatment) or any other treatments for people with schizophrenia or related psychoses. |
| Methods | Search methods: We searched Cochrane Schizophrenia Group's Trials Register (February 2012), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and clinical trials registries. We also inspected references of identified studies and contacted relevant authors for additional information. Selection CRITERIA: We included all relevant randomised controlled trials involving people with schizophrenia-like illnesses, comparing acupuncture added to standard dose antipsychotics with standard dose antipsychotics alone, acupuncture added to low dose antipsychotics with standard dose antipsychotics, acupuncture with antipsychotics, acupuncture added to Traditional Chinese Medicine (TCM) drug with TCM drug, acupuncture with TCM drug, electric acupuncture convulsive therapy with electroconvulsive therapy. Data collection and analysis: We reliably extracted data from all included studies, discussed any disagreement, documented decisions and contacted authors of studies when necessary. We analysed binary outcomes using a standard estimation of risk ratio (RR) and its 95% confidence interval (CI). For continuous data, we calculated mean differences with 95% CI. For homogeneous data we used fixed-effect model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. |
| Main results | After an update search in 2012 the review now includes 30 studies testing different forms of acupuncture across six different comparisons. All studies were at moderate risk of bias. When acupuncture plus standard antipsychotic treatment was compared with standard antipsychotic treatment alone, people were at less risk of being 'not improved' (n = 244, 3 RCTs, medium-term RR 0.40 CI 0.28 to 0.57, very low quality evidence). Mental state findings were mostly consistent with this finding as was time in hospital (n = 120, 1 RCT, days MD -16.00 CI -19.54 to -12.46, moderate quality evidence). If anything, adverse effects were less for the acupuncture group (e.g. central nervous system, insomnia, short-term, n = 202, 3 RCTs, RR 0.30 CI 0.11 to 0.83, low quality evidence).When acupuncture was added to low dose antipsychotics and this was compared with standard dose antipsychotic drugs, relapse was less in the experimental group (n = 170, 1 RCT, long-term RR 0.57 CI 0.37 to 0.89, very low quality evidence) but there was no difference for the outcome of 'not improved'. Again, mental state findings were mostly consistent with the latter. Incidences of extrapyramidal symptoms - akathisia, were less for those in the acupuncture added to low dose antipsychotics group (n = 180, 1 RCT, short-term RR 0.03 CI 0.00 to 0.49, low quality evidence) - as dry mouth, blurred vision and tachycardia. When acupuncture was compared with antipsychotic drugs of known efficacy in standard doses, there were equivocal data for outcomes such as 'not improved' using different global state criteria. Traditional acupuncture added to TCM drug had benefit over use of TCM drug alone (n = 360, 2 RCTs, RR no clinically important change 0.11 CI 0.02 to 0.59, low quality evidence), but when traditional acupuncture was compared with TCM drug directly there was no significant difference in the short-term. However, we found that participants given electroacupuncture were significantly less likely to experience a worsening in global state (n = 88, 1 RCT, short-term RR 0.52 CI 0.34 to 0.80, low quality evidence). In the one study that compared electric acupuncture convulsive therapy with electroconvulsive therapy there were significantly different rates of spinal fracture between the groups (n = 68, 1 RCT, short-term RR 0.33 CI 0.14 to 0.81, low quality evidence). Attrition in all studies was minimal. No studies reported death, engagement with services satisfaction with treatment, quality of life, or economic outcomes. |
| Authors' conclusions | Limited evidence suggests that acupuncture may have some antipsychotic effects as measured on global and mental state with few adverse effects. Better designed large studies are needed to fully and fairly test the effects of acupuncture for people with schizophrenia. |
1.1.7. Lee 2009 ☆
Lee MS, Shin BC, Ronan P, Ernst E.. Acupuncture for schizophrenia: a systematic review and meta-analysis. Int J Clin Pract. 2009;63(11): 1622-33. [150489].
| Objectives | Acupuncture is one of the most popular types of complementary/alternative medicine. It is sometimes used as a treatment for schizophrenia. AIMS: The objective of this review is to assess systematically the clinical evidence for or against acupuncture as a treatment for schizophrenia. |
| Methods | We searched 20 databases from their inception to May 2009 without language restrictions. All randomised clinical trials (RCTs) of acupuncture, with or without electrical stimulation or moxibustion for patients with schizophrenia were considered for inclusion. |
| Results | Thirteen RCTs, all originating from China, met the inclusion criteria. One RCT reported significant effects of electroacupuncture (EA) plus drug therapy for improving auditory hallucunations and positive symptom compared with sham EA plus drug therapy. Four RCTs showed significant effects of acupuncture for response rate compared with antipsychotic drugs [n = 360, relative risk (RR): 1.18, 95% confidence interval (CI): 1.03-1.34, p = 0.01; heterogeneity: tau(2) = 0.00, chi(2) = 2.98, p = 0.39, I(2) = 0%]. Seven RCTs showed significant effects of acupuncture plus antipsychotic drug therapy for response rate compared with antipsychotic drug therapy (n = 457, RR: 1.15, 95% CI: 1.04-1.28, p = 0.008, heterogeneity: tau(2) = 0.00, chi(2) = 6.56, p = 0.36, I(2) = 9%). Two RCTs tested laser acupuncture against sham laser acupuncture. One RCT found beneficial effects of laser acupuncture on hallucination and the other RCT showed significant effects of laser acupuncture on response rate, Brief Psychiatric Rating Scale and clinical global index compared with sham laser. The methodological quality was generally poor and there was not a single high quality trial. |
| Conclusions | These results provide limited evidence for the effectiveness of acupuncture in treating the symptoms of schizophrenia. However, the total number of RCTs, the total sample size and the methodological quality were too low to draw firm conclusions. As all studies originated from China, international studies are needed to test whether there is any effect. |
1.1.8. Rathbone 2005 Ø
Rathbone J, Xia J, Rathbone J. Acupuncture for schizophrenia. Cochrane Database Syst Rev. 2005. 4:CD005475. [140974].
| Background | Acupuncture has been shown to be a relatively safe health care intervention with few adverse effects. In contrast ,antipsychotic drugs can have seriously disabling adverse effects. However, the benefits of acupuncture in the treatment of schizophrenia are unclear, and further evidence is needed to inform clinicians and people with schizophrenia of its efficacy in the treatment of schizophrenia. |
| Objectives | To evaluate acupuncture for people with schizophrenia and related psychoses. |
| Methods | Search strategy: We (JR, JX) undertook electronic searches of the Cochrane Schizophrenia Group's register (April 2005). We inspected reference lists and contacted the first author of each included study. Selection criteria: We included all relevant randomised controlled trials involving people with schizophrenia-like illnesses, allocated to acupuncture, electro-acupuncture, laser-acupuncture, placebo, no treatment, or antipsychotic drugs produced by pharmaceutical companies were included. Data collection and analysis: We independently extracted the data. For homogeneous dichotomous data, the fixed effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, we calculated weighted mean differences with 95% CI. |
| Main results | We included five trials. Two trials comparing acupuncture to antipsychotics were equivocal for global state and leaving the study early. Extrapyramidal adverse events were significantly lower in the acupuncture group (n=21, RR 0.05 CI 0.0 to 0.8, NNT 2 CI 2 to 8). Four out of the five trials also compared acupuncture combined with antipsychotics to antipsychotics alone. Global state outcomes and leaving the study early were equivocal. BPRS endpoint data (short term) favoured the combined acupuncture and antipsychotic group (n=109, RR -4.31 CI -7.0 to -1.6), although dichotomised BPRS data 'not improved' confounded this outcome with equivocal data. Depression scores HAMD (n=42, WMD -10.41 CI -12.8 to -8.0), HAMD 'not improved' (n=42, RR 0.17 CI 0.1 to 0.5, NNT 2 CI 2 to 3) and ZDS (n=42, WMD -24.25 CI -28.0 to -20.5) significantly favoured the combined acupuncture/antipsychotic treatment group, although results were from single, small studies. Treatment emergent adverse events scores were significantly lower in the acupuncture/antipsychotic group (n=40, WMD -0.50 CI -0.9 to -0.1), again from a single, small study. |
| Authors' conclusions | we found insufficient evidence to recommend the use of acupuncture for people with schizophrenia. The numbers of participants and the blinding of acupuncture were both inadequate, and more comprehensive and better designed studies are needed to determine the effects of acupuncture for schizophrenia. |
1.2. Special Acupuncture Techniques
1.2.1. Comparison of Acupuncture techniques
1.2.1.1. Zhaohan 2023
Zhaohan H, Yuan F, Xiaolu W, Yue H, Qi YU, Tong W. Effectiveness of acupuncture-related therapies on schizophrenia: a Bayesian network Meta-analysis. J Tradit Chin Med. 2023 Apr;43(2):239-251. https://doi.org/10.19852/j.cnki.jtcm.20221226.001
| Objective | To create the hierarchical model for the comparison of efficacy of different ATs for schizophrenia. |
| Methods | PubMed, Web of Science, Embase, The Cochrane Library, ClinicalTrials, China National Knowledge Infrastructure Database, China Science and Technology Journal Database, Wanfang Database, and SinoMed were searched using a specified search strategy to identify relevant studies up to December 2021. The data were extracted independently by two reviewers. The quality of included trials was evaluated based on the guidelines of “Cochrane Handbook for Systematic Reviews of Interventions”. Bayesian network meta-analysis was conducted by statistical analysis software Addis 1.16.6 and Stata 15.1. |
| Results | In total, 60 randomized controlled trials covering 4810 patients were enrolled. The network meta-analysis result showed that Body Acupuncture (BA), BA + Electro-acupuncture (EA), Scalp Acupuncture (SA) + EA, Auricular Acupuncture (AA), Low-dose medication and Acupuncture (LA), Acupoint Injection (AI), and Acupoint Catgut Embedding (ACE), when combined with Western Medications (WM), demonstrated a better clinical effect at improving the symptoms of schizophrenia, compared to WM alone. Results of rank probability showed that BA, when combined with WM, was the most optimal AT for schizophrenia at decreasing three aspects of PANSS scale score. |
| Conclusions | Acupuncture-related therapies help improve the symptoms of schizophrenia, and BA combined with WM may be a better therapy for schizophrenia. This study has been registered on the “PROSPERO” website, and the registration number is CRD42021227403. |
2. Clinical Practice Guidelines
⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence) |
2.1. Department of Veterans Affairs Department of Defense (VA/DoD, USA) 2023 Ø
VA/DoD Clinical Practice Guideline for Management of First-Episode Psychosis and Schizophrenia. Washington, DC: U.S. Government Printing Office. 2023. https://www.healthquality.va.gov/guidelines/MH/scz/VADoDCPGSchizophreniaCPG_Final_508.pdf
| There is insufficient evidence to recommend for or against augmenting pharmacotherapy with acupuncture to reduce negative and positive symptoms for individuals with schizophrenia. Strength :Neither for nor against |
