Sommaire

Depression

syndrome dépressif

Articles connexes : - acupuncture expérimentale - qigong - pharmacopée -

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. Chen 2023

Chen B, Wang CC, Lee KH, Xia JC, Luo Z. Efficacy and safety of acupuncture for depression: A systematic review and meta-analysis. Res Nurs Health. 2023 Feb;46(1):48-67. https://doi.org/10.1002/nur.22284. Epub 2022 Dec 12. https://pubmed.ncbi.nlm.nih.gov/36509453

BackgroundAcupuncture 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.
MethodsThe 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.
Results 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).
ConclusionsAcupuncture, either in isolation or as an adjunct to pharmacological treatment, has clinical benefits and can be be considered a safe option for managing depression.

1.1.2. Wang 2022 (combined with paroxetine)

Wang Y, Zhang A, Dilinuer A, Hao L, Hu Z, Jia W. Meta-analysis of acupuncture combined with paroxetine in the treatment of depression. Am J Transl Res. 2022 Dec 15;14(12):8429-8436. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc9827301/

Objective To systematically evaluate the clinical efficacy of acupuncture combined with paroxetine in the treatment of depression.
MethodsThe research literature on the treatment of depression with acupuncture and moxibustion combined with paroxetine was collected using keywords in PubMed, Embase, Web of Science, Cochrane Library, CNKI, World Wide Web, Chinese Biomedical Literature and other public publication databases. Collaborative screening of literature was performed according to pre-established inclusion and exclusion criteria. The data in the literature were extracted, the quality of the literature was evaluated, and the RevMan software was used for statistical analysis.
ResultsThis study finally included 21 research papers involving 1733 clinical patients. The main evaluation indicators for clinical patients were Hamilton Depression Rating Scale (HAMD), total clinical response rate, Rating Scale for Side Effects (SERS) and Treatment Emergent Symptom Scale (TESS). SERS was developed by Asberg. The Chinese version was revised by Zhang Mingyuan (Chairman of the Chinese Medical Association Mental Health Society) et al. The SERS is divided into 14 items, all of which use a 4-point scoring method (none, mild, moderate and severe, respectively). This scale is mainly used to assess the side effects of antidepressants. TESS was compiled by the NIMH of the United States in 1973. It has the most comprehensive items and the widest coverage among the scales of its kind, including not only common adverse symptoms and signs, but also several laboratory test results. Meta-analysis of the above results showed that compared with the control group, the acupuncture combined with paroxetine treatment group showed lower HAMD score (WMD=-4.18 [-5.04, -3.31], P<0.001), higher total response rate (OR=4.01 [3.01, 5.33], P<0.001), lower SERS score (WMD=-2.54 [-4.58, -0.51], P<0.001) and lower TESS score (WMD=-4.39 [-5.15, -3.62], P<0.001), and the differences were statistically significant.
ConclusionThe therapeutic effect of acupuncture combined with paroxetine on depression is better than that of conventional drug treatment, and its safety is comparable to that of conventional treatment.

1.1.3. Xu 2022 (adjunct to antidepressants) ☆

Xu MM, Guo P, Ma QY, Zhou X, Wei YL, Wang L, Chen Y, Guo Y. Can acupuncture enhance therapeutic effectiveness of antidepressants and reduce adverse drug reactions in patients with depression? A systematic review and meta-analysis. J Integr Med. 2022 Jul;20(4):305-320. https://doi.org/10.1016/j.joim.2022.05.002

BackgroundSome depressed patients receive acupuncture as an adjunct to their conventional medications.
Objective This review aims to provide evidence on whether acupuncture can enhance the therapeutic effectiveness of antidepressants for treating depression, and explore whether acupuncture can reduce the adverse reactions associated with antidepressants.
MethodsSearch strategy. English and Chinese databases were searched for randomized controlled trials (RCTs) published until December 1, 2021. Inclusion criteria. RCTs with a modified Jadad scale score ≥ 4 were included if they compared a group of participants with depression that received acupuncture combined with antidepressants with a control group that received antidepressants alone. Data extraction and analysis. Meta-analysis was performed, and statistical heterogeneity was assessed based on Cochran's Q statistic and its related P-value. Primary outcomes were the reduction in the severity of depression and adverse reactions associated with antidepressants, while secondary outcomes included remission rate, treatment response, social functioning, and change in antidepressant dose. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence in the included studies.
Results This review included 16 studies (with a total of 1958 participants). Most studies were at high risk of performance bias and at low or unclear risk of selection bias, detection bias, attrition bias, reporting bias, and other bias. Analysis of the 16 RCTs showed that, compared with antidepressants alone, acupuncture along with antidepressants reduced the Hamilton Depression Rating Scale-17 (HAMD-17) scores (standard mean difference [SMD] -0.44, 95% confidence interval [CI] -0.55 to -0.33, P < 0.01; I2 = 14%), Self-rating Depression Scale (SDS) scores (SMD -0.53, 95% CI -0.84 to -0.23, P < 0.01; I2 = 79%), and the Side Effect Rating Scale (SERS) scores (SMD -1.11, 95% CI -1.56 to -0.66, P < 0.01; I2 = 89%). Compared with antidepressants alone, acupuncture along with antidepressants improved World Health Organization Quality of Life-BREF scores (SMD 0.31, 95% CI 0.18 to 0.44, P < 0.01; I2 = 15%), decreased the number of participants who increased their antidepressant dosages (relative risk [RR] 0.32, 95% CI 0.22 to 0.48, P < 0.01; I2 = 0%), and resulted in significantly higher remission rates (RR 1.52, 95% CI 1.26 to 1.83, P < 0.01; I2 = 0%) and treatment responses (RR 1.35, 95% CI 1.24 to 1.47, P < 0.01; I2 = 19%) in terms of HAMD-17 scores. The HAMD-17, SDS and SERS scores were assessed as low quality by GRADE and the other indices as being of moderate quality.
ConclusionAcupuncture as an adjunct to antidepressants may enhance the therapeutic effectiveness and reduce the adverse drug reactions in patients receiving antidepressants. These findings must be interpreted with caution, as the evidence was of low or moderate quality and there was a lack of comparative data with a placebo control.

1.1.4. Nguyen 2021 (combined with Paroxetine)

Nguyen MD, Nguyen QV, Ha CD, Van Tran T, Dang LVP. Beneficial Effects of Acupuncture as a Complementary Treatment for Patients Receiving Paroxetine For Major Depressive Disorder: A Meta-Analysis. Med Acupunct. 2021 Dec 1;33(6):420-427. https://doi.org/10.1089/acu.2021.0038

ObjectiveMajor depressive disorder (MDD) is a major public health problem due to MDD's increasing incidence among adults worldwide. While selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, are considered to be the most effective treatment for MDD, the adverse effects of SSRIs should not be neglected. The aim of this research was to evaluate the effectiveness of acupuncture as a complement to paroxetine systematically for improving quality of life (QoL) for patients with MDD.
Methods and MaterialsChinese and English electronic databases were searched, randomized controlled clinical studies were collected, data entry was managed, and a meta-analysis was performed to evaluate the QoL of the patients pre and post treatment.
ResultsThere were 5 studies included in the review, in which the researchers compared the QoL of patients with MDD treated with: paroxetine + acupuncture (both electroacupuncture and traditional acupuncture) or paroxetine alone. In all aspects-including physical health, psychologic health, social relationships, and environment-patients treated with the combination therapy experienced a significant improvements in QoL compared the patients treated with the single therapy.
Conclusions Using acupuncture as a complementary treatment improved QoL in patients with MDD.

1.1.5. Zhang 2021

Zhang Z, Li S, Meng H, Wang Y, Zhang Y, Wu M, Chen Y, Rong P, Wang Y. Efficacy and safety of acupuncture in the treatment of depression: A systematic review of clinical research. Anat Rec (Hoboken). 2021 Nov;304(11):2436-2453. https://doi.org/10.1002/ar.24783

BackgroundAs a common mental disorder, depression is one of the leading causes of disability around the world. Clinical studies have shown that acupuncture is an effective therapy without obvious side effects compared to limited efficacy and adverse reactions of drug therapy, cognitive behavioral therapy, and neuromodulation technology in treating depression. The objective of this review is to systematically evaluate whether acupuncture therapies for depression are safe and effective in order to provide a high-quality reference for clinical trials of acupuncture.
Methods A systematic search of the literature was carried out through bibliographic search engine PubMed. Subsequently, the study design, intervention methods, control group, results, and safety of acupuncture were analyzed.
ResultsThe results showed that acupuncture as an adjunct to antidepressants or as a single treatment can exert a positive impact on patients' depressive symptoms. Compared with antidepressants, acupuncture has the advantages of fast onset and long-term efficacy in the treatment of depression, and can enhance the efficacy of antidepressants. Moreover, the efficacy and safety of acupuncture in the treatment of depression maybe related to the qualification of the acupuncturist, the selection of acupoints, and intervention measures.

1.1.6. Zhichao 2021 ☆☆

Zhichao H, Ching LW, Huijuan L, Liang Y, Zhiyu W, Weiyang H, Zhaoxiang B, Linda ZLD. A network meta-analysis on the effectiveness and safety of acupuncture in treating patients with major depressive disorder. Sci Rep. 2021 May 17;11(1):10384. https://doi.org/10.1038/s41598-021-88263-y.

BackgroundAcupuncture is an important alternative therapy in treating major depressive disorder (MDD), but its efficacy and safety are still not well assessed. This study is the first network meta-analysis exploring the effectiveness and safety of acupuncture, common pharmacological treatments or other non-medication therapies for MDD.
Methods Eight databases including PubMed, Embase, Allied and Complementary Medicine Database, Cochrane Library, Wan Fang Data, China National Knowledge Infrastructure, China Biology Medicine disc, and Chongqing VIP Database were searched up to Jan 17, 2021. Articles were screened and selected by two reviewers independently. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.
Results A total of 71 eligible studies were included. The network analysis results indicated that the combined interventions of electro-acupuncture (EA) with selective serotonin reuptake inhibitors (SSRIs) and manual acupuncture (MA) with SSRIs were more effective in improving depression symptoms compared with acupuncture alone, pharmacological interventions alone, or other inactive groups. Among all the regimens, EA with SSRIs was found to have the highest effect in improving depression symptoms of MDD. In addition, there were slight differences in the estimations of the various treatment durations. The combination of acupuncture and serotonin-norepinephrine reuptake inhibitors (SNRIs) was found to be more effective than SNRIs alone.
ConclusionsIn conclusion, acupuncture and its combinations could be safe and effective interventions for MDD patients. EA with SSRIs seems to be the most effective intervention among the assessed interventions. Well-designed and large-scale studies with long-term follow-up should be conducted in the future.

1.1.7. Meng 2020 (combined with SSRIs) ☆☆

Meng Ying. [Effectiveness of Combined Electro-Acupuncture and SSRIs for Depression: A Systematic Review and Meta-analysis]. Chinese Journal of Ethnomedicine and Ethnopharmacy. 2020. [212941].

ObjectiveTo assess the clinical effectiveness of combined electro-acupuncture or acupuncture and SSRIs for depression.
Methods The following databases were searched: Pub Med, EMbase, The Cochrane Library, CBM, CNKI, VIP and Wan Fang Data databases. Only randomized controlled trials ( RCTs) were considered. Primary outcomes were effective rate and the Hamilton Rating Scale for Depression ( HAMD).
Results 23 trials involving 1682 patients were included. The result of this meta-analysis demonstrated that the acupuncture group had a significantly greater effective rate compared with the control group ( 22 trials, n =1462, I2= 0%; relative risk ( RR) 1. 17, 95% CI 1. 12 to 1. 23; P < 0. 00001). Moreover, the acupuncture group was superior to the control group in HAMD scores before and after treatment in 1 week and 2、4、6、8 weeks. ( 1 week, n = 877, I2= 65%, WMD= 2. 07, 95% CI 1. 06 to 3. 08; 2 week, n = 778, I2= 75%, WMD = 3. 46, 95% CI 2. 15 to 4. 77; 4 weeks, n = 1598, I2= 68%, WMD = 2. 93, 95% CI 2. 23 to 3. 62; 6 weeks, n = 747, I2= 52%, WMD = 3. 25, 95% CI 2. 25 to 4. 24; 8 weeks, n = 177, I2=94%, WMD = 5. 89, 95% CI 1. 28 to 10. 50). the result of this meta-analysis demonstrated that the acupuncture group had a lower adverse reaction rate compared with the control group ( 12 trials, n = 860, I2= 0%; relative risk ( RR) 0. 37, 95% CI 0. 26 to0. 53; P < 0. 00001). The acupuncture group was lower than control group in SERS scores before and after treatment in 2、4、6、8 weeks. ( n = 691, I2= 0%, WMD = 2. 42, 95% CI 2. 00 to 2. 84).
Conclusions Current evidence shows that electro-acupuncture or acupuncture combined with SSRIs is effective over the first 1-week, 2-week, 4-week, 6-week and 8-week treatment period. Moreover, this treatment combination appears to result in greater therapeutic efficacy and lower adverse reactions than antidepressant medication therapy alone.

1.1.8. Ting 2020 (combined with antidepressant) ☆

Ting Yuan. [Acupuncture and Moxibustion Combined with Western Medicine for Primary Depression: A Systematic Review and Meta Analysis ]. Journal of Basic Chinese Medicine. 2020. [212893].

Objective To systematically review the effectiveness and safety of acupuncture & moxibustion combined with western medicine for primary depression.
Methods A computer-based retrieval was performed in CNKI (1979~2018), CBM (1979~2018), VIP (1989~2018), WF (1998~2018), PubMed (1966~2018), EMbase (1980~2018) and Cochrane Library, supplemented by manual retrieval of relevant references. Collect randomized controlled trials (RCTs). The evidence quality was assessed by Jadad scale and Cochrane risk assessment tool. The Cochrane Collaboration's RevMan 5. 3. 0 software was used for meta analysis.
Results A total of 44 trials involving 3529 patients were included. Meta-analysis showed that the effects of acupuncture & moxibustion combined with western medicine were superior to western medicine in terms of the total efficiency rate, HAMD-17, HAMD-24, SDS score, TESS score, SERS score, CGI score.
Conclusion Acupuncture and moxibustion combined with western medicine in the treatment of primary depression is more effective than western medicine therapy, and it is worth noting that acupuncture & moxibustion is associated with few adverse reactions. Because of the generally low quality of the included literatures, it still needs further large-scale and high-quality randomized controlled trials to verify the effectiveness and safety of acupuncture and moxibustion in the treatment of primary depression.

1.1.9. Armour 2019 ☆

Armour M , Smith CA , Wang LQ, Naidoo D, Yang GY, MacPherson H, Lee MS, Hay P. Acupuncture for Depression: A Systematic Review and Meta-Analysis. J Clin Med. 2019;8(8). [200020].

BackgroundDepression 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.
MethodsA 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.
ResultsTwenty-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.
ConclusionsAcupuncture may be a suitable adjunct to usual care and standard anti-depressant medication.

1.1.10. Chen 2019

Chen C , Shan W. Pharmacological and non-pharmacological treatments for major depressive disorder in adults: A systematic review and network meta-analysis. Psychiatry Res. 2019. [202148]. doi

Objectives Depression has brought huge disease burden to the world. This systematic review aimed to compare the efficacy and safety of pharmacological and non-pharmacological treatments for major depressive disorder (MDD).
MethodsWe searched electronic databases with time range from 1990.1.1 to 2018.9.5. Randomized controlled trials (RCTs) including adult patients with MDD were eligible for inclusion. We conducted network meta-analyses using multivariate meta-analyses models under the frequency framework. Primary outcomes were efficacy (response rate) and safety (overall risk of adverse events).
ResultsWe estimated summary odds ratios (Ors) based on group-level data. 20,937 citations were identified, 91 trials comprising 10,991 participants were included in efficacy study, and 32 trials comprising 5245 participants were included in safety study. In terms of efficacy, all treatments studied (acupuncture, mirtazapine, herbal medicine, venlafaxine, physical exercise, cognitive-behavioral therapy (CBT), bupropion, fluoxetine, and vortioxetine) except for probiotics were significantly more effective than placebo. In terms of safety, bupropion, fluoxetine, venlafaxine, and vortioxetine were significantly less safe than placebo. Herbal medicine and mirtazapine had no significant difference in overall risk of adverse events compared with placebo. Acupuncture, CBT, physical exercise and probiotics were lack of eligible safety data.

1.1.11. Zang 2019 (+ insomnia)

Zang Yingying, Wang Zhaoyang, Chen Xinli, Liu Yueting, Qiu Linghui. [Meta-analysis of clinical efficacy and safety of acupuncture for treatment of depression with insomnia]. Journal of Beijing University of Traditional Chinese Medicine (Clinical Medicine). 2019;2:18-24,29. [201727].

目的 系统评价针刺对照常规医药治疗抑郁症睡眠障碍的疗效和安全性.方法 计算机检索Pubmed、Embase、Cochrane Library、中国生物医学文献数据库、中国知网和万方数据库,由2名评价员分别独立检索针刺治疗抑郁症睡眠障碍的临床随机对照试验,检索时限为建库至2018年3月.由2名评价者独立检索、提取资料和评估方法学质量后,采用RevMan 5.3软件进行Meta分析.结果 最终纳入15个研究,共1081例受试者,Meta分析结果显示:(1)针刺组疗效与常规西药对照组无明显差异:①有效率:OR=1.55,95%CI(0.87,2.78);②汉密尔顿抑郁量表评分:OR=-1.47,95%CI(-3.44,0.50);③匹兹堡睡眠质量指数评定量表评分:OR=-2.07,95%CI(-4.26,0.13);④抑郁症测试表(SDS)抑郁严重度指数评分:OR=-3.31,95%CI(-5.22,-1.40),SDS评分:OR=-0.04,95%CI(-0.10,0.02).(2)治疗后复发率针刺组与常规西药对照组无明显差异:①治疗后1个月随访:OR=0.43,95%CI(0.16,1.16);②治疗后3个月随访:OR=0.49,95%CI(-3.51,-2.71).(3)不良反应发生率针刺组优于西药对照组:不良反应量表评分:OR=-3.38,95%CI(-4.84,-1.92).结论 本Meta分析结果显示,针刺治疗抑郁症睡眠障碍具有较好的临床疗效,不良反应发生率较常规西药低.

[Automatic translation].
Objective To systematically evaluate the efficacy and safety of acupuncture versus conventional medicine in the treatment of depression in children with insomnia.
Methods Computer search for Pubmed, Embase, Cochrane Library, China Biomedical Literature Database, China Knowledge Network and Wanfang Database, independently by 2 evaluators A randomized controlled trial of acupuncture for the treatment of depression in children with with insomnia was performed. The search time limit was from Jianku to March 2018. After two independent reviewers searched, extracted data and assessed methodological quality, MetaMan analysis was performed using RevMan 5.3 software.
Results 15 studies were finally included, a total of 1081 subjects. Meta-analysis showed: (1)There was no significant difference between the acupuncture group and the conventional western medicine control group: 1 Effective rate: OR=1.55, 95% CI (0.87, 2.78)2; Hamilton Depression Scale score: OR = -1.47, 95% CI (-3.44, 0.50); 3 Pittsburgh Sleep Quality Index Rating Scale: OR = -2.07, 95% CI (-4.26, 0.13); Depression Test Scale (SDS)Depression Severity Index score: OR=-3.31, 95% CI (-5.22, -1.40), SDS score: OR=-0.04, 95% CI (-0.10, 0.02). (2)There was no significant difference between the acupuncture group and the conventional western medicine control group after treatment: 1 1 month follow-up after treatment: OR=0.43,9 5% CI (0.16, 1.16); 2 3 months follow-up after treatment: OR=0.49, 95% CI (-3.51, -2.71). (3)incidence of adverse reactions acupuncture group is better than western medicine control group: adverse reactions Scale score: OR=-3.38, 95% CI (-4.84, -1.92).
Conclusions The results of this meta-analysis show that acupuncture has a good clinical effect in treating depression with with insomnia, and the incidence of adverse reactions is higher than that of conventional western medicine.

1.1.12. Smith 2018 ☆

Smith CA, Armour M, Lee MS, Wang LQ, Hay PJ. Acupuncture for depression. Cochrane Database Syst Rev. 2018. [160424].

BackgroundDepression 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.
MethodsSEARCH 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 clinician-rated scales, and improvement in depression, defined as remission versus no remission. We assessed evidence quality using the GRADE method.
Main resultsThis 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 usual. We found low-quality evidence suggesting that outcomes were reduction in the severity of depression, measured by self-rating scales or by 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 medication. We 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 alone. We 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 therapy. It 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.

1.1.13. Asher 2017 Ø

Asher GN, Gartlehner G, Gaynes BN, Amick HR, Forneris C, Morgan LC, Coker-Schwimmer E, Boland E, Lux LJ, Gaylord S, Bann C, Pierl CB, Lohr KN. Comparative Benefits and Harms of Complementary and Alternative Medicine Therapies for Initial Treatment of Major Depressive Disorder: Systematic Review and Meta-Analysis. J Altern Complement Med. 2017;23(12):907-919. [52493].

Objectives To report the comparative benefits and harms of exercise and complementary and alternative medicine (CAM) treatments with second-generation antidepressants (SGA) for major depressive disorder (MDD).
MethodsDESIGN: Systematic review and meta-analysis. SETTINGS: Outpatient clinics. SUBJECTS: Adults, aged 18 years and older, with MDD receiving an initial treatment attempt with SGA. INTERVENTIONS: Any CAM or exercise intervention compared with an SGA. OUTCOME MEASURES: Treatment response, remission, change in depression rating, adverse events, treatment discontinuation, and treatment discontinuation due to adverse events.
Results We found 22 randomized controlled trials for direct comparisons and 127 trials for network meta-analyses, including trials of acupuncture, omega-3 fatty acids, S-adenosyl methionine, St. John's wort, and exercise. For most treatment comparisons, we found no differences between treatment groups for response and remission. However, the risk of bias of these studies led us to conclude that the strength of evidence for these findings was either low or insufficient. The risk of treatment harms and treatment discontinuation attributed to adverse events was higher for selective serotonin receptor inhibitors than for St. John's wort.
ConclusionsAlthough we found little difference in the comparative efficacy of most CAM therapies or exercise and SGAs, the overall poor quality of the available evidence base tempers any conclusions that we might draw from those trials. Future trials should incorporate patient-oriented outcomes, treatment expectancy, depressive severity, and harms assessments into their designs; antidepressants should be administered over their full dosage ranges; and larger trials using methods to reduce sampling bias are needed.

1.1.14. Sorbero 2016 Ø

Sorbero ME, Reynolds K, Colaiaco B, Lovejoy SL, Farris C, Vaughan CA, Sloan J, Kandrack R, Apaydin E, Herman PM. Acupuncture for Major Depressive Disorder: A Systematic Review. Rand Health. 2016;:135p. [190919].

Objectives Major depressive disorder (MDD) is a prevalent condition associated with significant burden in terms of reduced quality of life, lower productivity, increased prevalence of other conditions and increased health care costs. We conducted a systematic review and qualitative summary of randomized controlled trials (RCTs) that assessed the effectiveness and safety of acupuncture for the treatment of MDD.
Methods We searched the databases PubMed, CINAHL, PsycINFO, Web of Science, Embase, CDSR, CENTRAL, clinicaltrials.gov, DARE, and PILOTS for English-language RCTs published through January 2015. Two independent reviewers screened the identified literature against inclusion and exclusion criteria, abstracted study level data, and assessed the risk of bias and methodological quality of included studies. The quality of the evidence was assessed using GRADE.
Results Eighteen studies met inclusion criteria. Eleven assessed acupuncture as monotherapy, seven as adjunct depression treatment. Intervention approaches and comparators varied. Evidence on the effectiveness and comparative effectiveness of acupuncture to treat MDD for the outcomes depression improvement, measured as scale score differences and the number of responders, is very weak. Acupuncture may be superior to waitlist (low quality of evidence) but findings for effect estimates compared to other comparators are inconclusive. Few studies reported on patients achieving remission.
Conclusions The effect of acupuncture on relapse rates could not be determined. Too few studies assessed quality of life to estimate treatment effects. Reported adverse events were typically mild in nature, but the assessment lacked rigor and studies were not designed to detect rare events.

1.1.15. Li 2016 ☆☆

Li Bo, Du Yuan-Hao, Liu Qiang. [Study to evaluate effficacy. intervention-level of acupuncture therapy based on Meta-analysis of ordinal data: major depressive disorder]. Tianjin Journal of Traditional Chinese Medicine. 2016;3:. [187059].

Objectives Based on high quality data clinical evidence and Meta-analysis of ordinal data model to evaluate the efficacy, intervention-level of acupuncture treatment of major depressive disorder (MD-D)
Methods The published papers on clinical trails for acupuncture treatment of MD-D were widely retrieved from Chinese and abroad Database. Quality of clinical evidence was evaluated by Jadad scale. Using the maximum likelihood method to fit the cumulative odds model, STATA12. 0 software was used for data analyses.
Results The 13 studies accord with the inclusive criterion were retrieved. Meta-analyses of ordinal data showed acupuncture compare with SSRIs increase the possibility of efficacy an increase of more than one level of 55%; acupuncture with SSRIs increase the possibility of efficacy an increase of more than one level of 183%.
Conclusions According to the present stage clinical evidences, treatment mild and moderate MD-D acupuncture can be used as the main treatment method, with antidepressants can significantly improve the overall efficacy.

1.1.16. Gartlehner 2015 ☆

Gartlehner G, Gaynes BN, Amick HR, Asher G, Morgan LC, Coker-Schwimmer E, Forneris C, Boland E, Lux LJ, Gaylord S, Bann C, Pierl CB, Lohr KN. Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder [Internet]. AHRQ Comparative Effectiveness Reviews. 2015. [167561].

Objectives To compare the benefits and harms of second-generation antidepressants (SGAs), psychological, complementary and alternative medicine, and exercise treatment options as first-step interventions for adult outpatients with acute-phase major depressive disorder (MDD), and as second-step interventions for patients with MDD who did not achieve remission after a first treatment attempt with SGAs
Methods DATA SOURCES: MEDLINE® (via PubMed®), Embase®, the Cochrane Library, AMED (Allied and Complementary Medicine Database), PsycINFO®, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from January 1, 1990, through January 13, 2015. REVIEW METHOD: Two investigators independently selected, extracted data from, and rated risk of bias of studies. We graded strength of evidence based on established guidance.
Results Forty-four trials met inclusion criteria. For benefits across all interventions, we graded the strength of evidence as moderate for only one outcome of one comparison: SGAs compared with cognitive behavioral therapy (CBT). Results indicate that SGAs and CBT had similar effectiveness regarding symptomatic relief in patients with mild to severe MDD. For risk of harms, we graded the strength of evidence as moderate for some outcomes of three comparisons—namely, SGAs compared with CBT, acupuncture, and St. John’s wort. Patients treated with SGAs had a higher risk of experiencing adverse events or discontinuing treatment because of adverse events than patients treated with CBT, acupuncture, or St. John’s wort. Our confidence in the benefits and harms of SGAs compared with the remaining treatment options is low or insufficient, indicating that the bodies of evidence had major or unacceptable deficiencies. Nevertheless, for most comparisons, the overall findings indicated no statistically significant differences in benefits but a lower risk of adverse events for nonpharmacological treatment options. Across all comparisons of interventions, major research gaps pertain to information about the comparative risk of harms and patient-relevant outcomes such as functional capacity and quality of life. For second-step therapies (i.e., therapy for patients with MDD who did not achieve remission after a first treatment attempt with SGAs), comparative evidence is limited. However, available data suggest that switching to another SGA, switching to cognitive therapy, and augmenting with a particular medication or cognitive therapy are all reasonable options.
Conclusions Overall, the available evidence indicates that SGAs and CBT do not differ significantly in symptomatic relief as first-step treatments for adult outpatients with moderate to severe MDD. SGAs, in general, lead to a higher risk of adverse events than nonpharmacological treatment options. The evidence is insufficient to form conclusions about differences in serious adverse events, such as suicidal ideas and behavior. Given comparable effectiveness, the choice of the initial treatment of MDD should consider results of previous treatments, patient preferences, and feasibility (e.g., costs, likely adherence, and availability) following a discussion of the advantages and disadvantages of each treatment option, including risks of particular adverse effects and potential drug interactions. Such shared and informed decisionmaking might enhance treatment adherence and improve treatment outcomes for patients with MDD, especially because treatment continuity is one of the main challenges in treating such patients.
Acupuncture SGAs and acupuncture monotherapy did not lead to statistically different response rates in patients with severe MDD following 6 weeks of treatment (two RCTs, network metaanalysis, low Strength of Evidence). • Adding acupuncture to SGA treatment improved treatment responses compared with SGAs alone in patients with severe MDD after 6 weeks of treatment (2 RCTs, low Strength of Evidence), but did not lead to statistically different rates of remission (1 RCT, low Strength of Evidence).

1.1.17. 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.

1.1.18. Shen 2014

Shen Hui, Zhang Jie, Yang Zuo, Yang Ni. [Systematic review of randomized controlled trials of acupuncture for depression]. Journal of New Chinese Medicine. 2014;46(6):220-2. [168567].

Cité et analysé dans Guo 2019

1.1.19. Ravindran 2013 ☆

Ravindran AV, Da Silva TL. Complementary and Alternative Therapies as Add-On to Pharmacotherapy for Mood and Anxiety Disorders: A Systematic Review. J Affect Disord. 2013;150(3):707-19. [174008].

Objectives Depressed and anxious patients often combine complementary and alternative medicine (CAM) therapies with conventional pharmacotherapy to self-treat symptoms. The benefits and risks of such combination strategies have not been fully evaluated. This paper evaluates the risk-benefit profile of CAM augmentation to antidepressants in affective conditions.
Methods PubMed was searched for all available clinical reports published in English up to December 2012. Data were evaluated based on graded levels of evidence for efficacy and safety.
Results Generally, the evidence base is significantly larger for depression than for anxiety disorder. In unipolar depression, there is Level 2 evidence for adjunctive sleep deprivation (SD) and Free and Easy Wanderer Plus (FEWP), and Level 3 for exercise, yoga, light therapy (LT), omega-3 fatty acids, S-adenosylmethionine and tryptophan. In bipolar depression, there is Level 1 evidence for adjunctive omega-3s, Level 2 for SD, and Level 3 for LT and FEWP. In anxiety conditions, exercise augmentation has Level 3 support in generalized anxiety disorder and panic disorder. Though mostly well-tolerated, these therapies can only be recommended as third-line interventions due to the quality of available evidence. LIMITATIONS: Overall, the literature is limited. Studies often had methodological weaknesses, with little information on long-term use and on potential drug-CAM interactions. Many CAM studies were not published in English.
Conclusions While several CAM therapies show some evidence of benefit as augmentation in depressive disorders, such evidence is largely lacking in anxiety disorders. The general dearth of adequate safety and tolerability data encourages caution in clinical use
Acupuncture To summarize, the findings are promising but poor quality and heterogeneity of published studies preclude definitive recommendations for the use of acupuncture augmentation in unipolar depression, bipolar disorder or anxiety disorders.

1.1.20. Wu 2012 ☆

Wu J, Yeung AS, Schnyer R, Wang Y, Mischoulon D. Acupuncture for Depression: A Review of Clinical Applications. Can J Psychiatry. 2012;57(7):397-405. [166275].

Objectives While increasing numbers of patients are seeking acupuncture treatment for depression in recent years, there is limited evidence of the antidepressant (AD) effectiveness of acupuncture. Given the unsatisfactory response rates of many Food and Drug Administration-approved ADs, research on acupuncture remains of potential value. Therefore, we sought to review the efficacy and safety of acupuncture treatment for depression in clinical applications.
Methods We conducted a PubMed search for publications through 2011. We assessed the adequacy of each report and abstracted information on reported effectiveness or efficacy of acupuncture as monotherapy for major depressive disorder (MDD) and as augmentation of ADs. We also examined adverse events associated with acupuncture, and evidence for acupuncture as a means of reducing side effects of ADs.
Results Published data suggest that acupuncture, including manual-, electrical-, and laser-based, is a generally beneficial, well-tolerated, and safe monotherapy for depression. However, acupuncture augmentation in AD partial responders and nonresponders is not as well studied as monotherapy; and available studies have only investigated MDD, but not other depressive spectrum disorders. Manual acupuncture reduced side effects of ADs in MDD. We found no data on depressive recurrence rates after recovery with acupuncture treatment.
Conclusions Acupuncture is a potential effective monotherapy for depression, and a safe, well-tolerated augmentation in AD partial responders and nonresponders. However, the body of evidence based on well-designed studies is limited, and further investigation is called for.

1.1.21. Dirmaier 2012 ~

Dirmaier J, Steinmann M, Krattenmacher T, Watzke B, Barghaan D, Koch U et al. Non-pharmacological treatment of depressive disorders: a review of evidence-based treatment options. Rev Recent Clin Trials 2012. 7(2):141-9. [166419].

BackgroundThe primary goals of this paper are to describe the collection and evaluation of various nonpharmacological treatment options for depressive disorders and to establish a basis for the development of a standard for the treatment of patients with depressive disorders.
Method To identify evidence-based treatment elements, a comprehensive investigation of national and international guidelines was conducted. The extracted guidelines were then assessed with regard to aspects of methodological quality and evidence-based treatment elements. In a further step, specific and systematic literature searches for residual treatment elements were conducted. For the corresponding literature search, a hierarchical approach was chosen in which current guidelines were reviewed first and systematic reviews and meta-analyses second. Psychopharmacological treatments were excluded from the analysis because this is covered by specific guidelines.
ResultsThe treatment elements with an adequate level of evidence were identified as follows: psychotherapeutic interventions, marital/couples/family therapy and counseling, inclusion of family members, psycho-education, exercise, problem solving therapy, guided self-help and behavioral activation treatments. Further evidence-based methods include diagnostic treatment elements, participative decision-making, development of the therapeutic alliance, Cognitive Behavioral Analysis System for Psychotherapy, computerized cognitive behavior therapy, psychopharmacological therapy, combined psychopharmacological and psychotherapeutic therapy, electroconvulsive therapy, phototherapy, sleep deprivation, repetitive trans-cranial magnetic stimulation (rTMS) and acupuncture.
Conclusion In summary, using a hierarchical approach, it was possible to assign different levels of evidence to the various treatment options for depression.

1.1.22. Bian 2011 ☆

Bian Xing-Kun, Fu Li-Xin, Zuo Xiao-Hong. [Acupuncture versus medicine for depression in china: a systematic review]. Journal of Clinical Acupuncture and Moxibustion. 2011. 27(8):59. [174503].

Objective To assess the therapeutic effect of acupuncture on depression.
Methods The literatures of acupuncture for treatment of depression are comprehensively searched in accordance with the demands of the evidence - based medicine (EBM ) , which are collected from relevant domestic medical literature databases in the last ten years. Meta - analysis is conducted on the literatures enrolled.
Results Fourteen randomized controlled trials are included, all of them are carried out by Meta - analysis. The total OR is 2. 65 [2. 04,3. 43], and the funnel plot is approximately symmetry. It is indicated that the curative effect of acupuncture groups is better than that in the control groups ( Z = 7. 30 P <0. 000 01).
Conclusion Acupuncture therapy is effective on depression according to the domestic clinical literatures. However,the quality of the studies needs further improving and increasing.

1.1.23. Nahas 2011 ∅

Nahas R, Sheikh O. Complementary and alternative medicine for the treatment of major depressive disorder. Can Fam Physician. 2011;57(6):659-63. [156464]

Objectifs To review the clinical evidence supporting complementary and alternative medicine interventions for treating major depressive disorder.
Méthodes PubMed was searched from January 1966 to February 2010 using the term depressive disorder in combination with St John's wort [Hypericum Perforatum], S-adenosylmethionine (SAM-e), exercise, acupuncture, omega-3 fatty acids, and folate. Only relevant human trials were selected.
Résultats In a large meta-analysis, St John's wort was found to be equivalent to antidepressant drugs with fewer side effects. Exercise reduced depressive scores in 3 meta-analyses. Omega-3 fatty acids reduced depressive scores in a meta-analysis of 16 trials, but publication bias was identified. Oral SAM-e monotherapy reduced depressive scores in 4 of 5 small randomized controlled trials. Folate deficiency is associated with more severe and refractory depression, and supplementation reduced depressive scores in 2 of 3 randomized controlled trials. Acupuncture demonstrated limited efficacy in 1 meta-analysis and 5 other trials.
Conclusions St John's wort and regular exercise appear effective in the treatment of depression. Acupuncture appears ineffective for depression, but it might offer other health benefits. Other promising therapies include SAM-e, omega-3 fatty acid, and folic acid supplementation in selected patients; further study is warranted.

1.1.24. Stub 2011

Stub T, Alræk T, Liu JL. Acupuncture treatment for depression—A systematic review and meta-analysis. European Journal of Integrative Medicine. 2011;3(4):e259-e270. [206474]. doi

Aim of the study To assess the beneficial effects of acupuncture in patients with depression and to evaluate the report quality of acupuncture treatment for depression in randomized controlled trials and systematic reviews.
Introduction Acupuncture has a long history of treating illnesses which we today in a biomedical context would understand and recognize as depression. Also in contemporary China and in the West patients are trying acupuncture as a treatment for depression. Randomized controlled trials have been conducted to investigate its efficacy.
Materials and methods The following electronic databases were searched: the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO and PUBMED. These searches ended in January 2009. In addition new searches were completed in Asian databases in February 2010. Standard guidelines were followed when the methodological quality of the RCTs were assessed, including CONSORT and the criteria in the Cochrane Handbook. Systematic reviews were evaluated using the PRISMA checklist.
Results Four systematic reviews and 26 RCTs on acupuncture for treatment of depression were identified and included in this review. The methodological quality of the trial reports was generally low in terms of generation of the allocation sequence, allocation concealment, blinding and intention to treat. A significant beneficial effect was found for acupuncture in improvement of depression compared to pooled control measured by Hamilton Rating Scale for Depression (WMD −3.10, 95% CI −4.91 to −1.99, P = 0.0008). Subgroup analysis suggested that electro-acupuncture (WMD −0.68, 95% CI −1.49 to 0.13, P = 0.10) and TCM acupuncture (WMD 0.79, 95% CI −0.93 to 2.52, P = 0.37), were not statistically different from medication. Acupuncture was regarded as generally safe in the clinical trials included in this review.
Conclusions Current evidence from this meta-analysis of randomized trials shows that acupuncture is effective in reducing severity of depression and that TCM- and electro acupuncture may have similar effect as current usual care. More rigorous trials are needed and long-term effects should be investigated if acupuncture is to be recommended for clinical use.

1.1.25. Smith 2010 Ø

Smith CA, Hay PP, Macpherson H. Acupuncture for depression. Cochrane Database Syst Rev. 2010. [155407].

BackgroundThere 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.
ObjectivesTo examine the effectiveness and adverse effects of acupuncture in the treatment for depression.
Methods 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 resultsThis 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.

1.1.26. 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].

BackgroundAlthough 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).
Methods Following systematic review, meta-analysis was conducted on high-quality randomized controlled trials (RCTs).
ResultsOf 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.
ConclusionsAcupuncture 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.

1.1.27. Fan 2010 ☆

Fan L, Fu W, Xu N, Liu J, Ou A, Wang Y. [Meta-analysis of 20 clinical, randomized, controlled trials of acupuncture for depression]. Neural Regeneration Research. 2010;5(24):1862-9. [140882].

Objectives To determine the efficacy of acupuncture in the treatment of depression by performing systematical reviews and meta-analysis from 20 articles of clinical, randomized, controlled studies.
Methods DATA SOURCES: A computer-based online search of PubMed Database, Chinese Biological Medicine Database (VIP database), China Knowledge Database, and Wanfang Database was performed to search articles published between January 1999 and September 2009. DATA SELECTION: Inclusion criteria: articles published in official academic journals; articles with definite diagnostic criteria and acknowledgment; articles involving subjects with depression or depressive disorders, with no limitations to age, sex, or source; articles involving acupuncture-related therapies (including acupuncture needle, electro-acupuncture, moxibustion, abdominal acupuncture, etc.) as the primary means of intervention; articles of randomized controlled trials or involving “randomized controlled”, “randomized grouping”, or “random”. Jadad scores were utilized to evaluate quality of included articles. Review Manage 4.2.7 software was used to evaluate efficacy of acupuncture in treating depression, and Hamilton Depression Rating Scale (HAMD) score, Self-Rating Depression Scale (SDS) score, and meta-analysis were used to evaluate clinical efficacy. Meta-analysis of a fixed effect model was performed when P > 0.05 or P > 0.01 in the test for heterogeneity. Meta-analysis of the random effect model was performed when P≤0.05. MAIN OUTCOME MEASURES: Efficacy rate, HAMD scores, and SDS scores.
Results Quality evaluation of the 20 selected clinical, randomized, controlled trials demonstrated baseline equilibrium and randomness, although a considerable number of randomized studies simply mentioned “random” without describing a specific method. Therefore, the reliability of randomness was relatively low. An envelope to hide the information was not used, and proper blinding was difficult to implement due to the innate features of acupuncture. The follow-up rate was low, and reasons for dropout were not explored. Therefore, it was not possible to objectively evaluate the study results. In addition, the study did not estimate sample size; it was unclear whether the sample was truly representative of general characteristics. Meta-analysis showed that acupuncture monotherapy exhibited similar efficacy to Western medicine for treating depression: combined effect size OR = 1.66, 95% CI: 0.59 -4.65, combined effect value test: Z= 0.97, P = 0.33. Comparison of the efficacy of acupuncture combination therapy with Western medicine demonstrated a combined effect size OR = 2.46, 95% CI: 1.64-3.71 and combined effect of the value of Z= 4.32 (P < 0.01), implying that there was insufficient evidence to prove a superior effect of acupuncture combination therapy over Western medicine. In terms of HAMD and SDS scores, the weighted mean difference was -2.01 and -8.68, respectively, with 95% Cl: -3.48 to 0.53, -11.21 to -6.16 (P < 0.01), suggesting that acupuncture efficacy was significantly better than the control group
Conclusions The efficacy of acupuncture monotherapy was similar to Western medicine for treating depression. However, efficacy of combination therapy remains uncertain due to inadequate study design (implementation of randomization and blinding, sample size estimation, and data processing methods).

1.1.28. Fan 2010 ∼

Fan Ling, Fu Wenbin, Xu Nenggui, Liu Jianhua, Ou Aihua, Wang Zuowen. [Meta-analysis of randomized controlled trials on acupuncture and moxibustion treating depression]. Chinese Journal of Gerontology. 2010;18: 2561-25. [186943].

Objectives To assess and analyze the randomized controlled trials on acupuncture and moxibustion treating depression.
Methods Relative clinical research literatures published from in January 1989 to 2009 in September were collected. A systematic assessment of two hundred and thirty five papers which conformed with the enrolled criteria was made with Review Manage4. 2. 7.
Results In the recent years, the study of acupuncture treatment of depression had been paid more and more attention. The number of articles published showed an upward trend year by year, but the quality was generally not high.
Conclusions Strengthening the study of comprehensive acupuncture treatment of depression and the randomization, large sample study and standardized treatment time, exploring feasible blind acupuncture are urgent to be resolved at present.

1.1.29. Xiong 2009 ☆

Xiong Jun, Du Yuan-Hao, Liu Jia-Lin, Lin Xiao-Miao, Sun Pan, Xiao Li, Gao Xiang, Chen Yuan-Wu. [Acupuncture versus western medicine for depression neurosis: a systematic review]. Chinese Journal of Evidence-Based Medicine. 2009;9(9):969-75.[166548]

Objectives To assess the efficacy and safety of acupuncture versus western medicine in the treatment of depression neurosis.
Methods Randomized controlled trials (RCTs) involving acupuncture versus western medicine in the treatment of depression neurosis were identified from CBM (1978 to 2009),VIP (1989 to 2009),WANFANG Database (1998 to 2009), CNKI (1979 to 2009), PubMed (1966 to 2009), Embase (1980 to 2009), and The Cochrane Library (Issue 4,2008). We also hand searched relevant journals from Tianjin University of Traditional Chinese Medicine. Data were extracted and evaluated by two reviewers independently with a specially designed extraction form. The Cochrane Collaboration’s RevMan 5.0.2 software was used for data analyses.
Results A total of 9 trials involving 903 patients were included. Meta-analyses showed that the total effective rate in the acupuncture group was similar when compared with Dailixin (RR= 1.01, 95%CI 0.82 to 1.23) on 20 d, fluoxetine (RR= 1.06, 95%CI 0.82 to 1.37) at week 8, but showing difference between acupuncture and fluoxetine (RR= 1.15, 95CI 1.07 to 1.22) at week 12. As for the HAMD score, no significant difference was noted between acupuncture and Dailixin (WMD= 0.45, 95%CI – 2.47 to 3.37) at 20 d, or amitriptyline at week 6, or fluoxetine on 30 d, and weeks 4, 8, 12; there was a difference between acupuncture and amitriptyline observed at week 1 (WMD= – 2.67, 95%CI – 4.38 to – 0.96) and week 2 (WMD= – 2.18, 95%CI – 3.28 to – 1.08). In terms of the SDS scores, significant difference was found between acupuncture and fluoxetine (WMD= – 4.26, 95%CI – 6.67 to – 1.85) at week 6, but no difference at week 4 and 12. Four trials reported adverse events. One trial found that no adverse events existed in acupuncture according with TESS score, contrasting with thirst, constipation, vision vague, shimmy, fast heart rate, and some change in liver function and cardiogram in amitriptyline group.Two trials reported very low score in acupuncture showing difference when compared with the drugs. And one trial described that four people had stomach and intestinal tract disorders. While no adverse reactions happened in the acupuncture group.
Conclusions Acupuncture is not inferior to western medicine, and it is worth noting that acupuncture is associated with few adverse reactions. Further large-scale trials are required to define the role of acupuncture in the treatment of depression neurosis.

1.1.30. Zhong 2008 ☆

Zhong Bao-Liang,Huang Yue-Qin,Li Hui-Juan. [The Effectiveness and Safety of Acupuncture for Depression:A systematic assessment]. Chinese Mental Health Journal. 2008;22:641-7. [165262].

Objectives To evaluate the efficacy and safety of acupuncture for depression.
Methods Cochrane systematic review method was applied.A number of English,Chinese,Japanese and Korean medical databases were searched,and most of the randomized controlled trials of acupuncture for depression were collected.According to Jadad criterion,the quality was evaluated,and the data were extracted by two independent authors.A descriptive systematic assessment and Meta-analysis were performed.
Results Seven high quality trials involving 895 patients were included in this systematic review.In one study,there was a statistically significant difference between acupuncture and waitlist groups on the Hanmilton Rating Scale for Depression(HAMD) score(WMD =-4.79,95%CI :-6.17,-3.14);In another study,no statistically significant difference was found between electroacupuncture and fluoxetine groups(WMD =-1.15,95%CI:-4.24,1.94);In the other two studies,no statistically significant difference was found between acupuncture combined with auricular acupuncture and fluoxetine groups on the HAMD score(WMD =-0.87,95%CI:-2.08,0.35).
Conclusions Based on current evidence,acupuncture is a promising treatment for depression.Electroacupuncture for major depressive disorder and acupuncture combined with auricular acupuncture for depressive neurosis have the same effectiveness as fluoxetine.The safety of acupuncture is good with slight and transient adverse effect.More follow-up studies are needed for evaluating the long-term effect of acupuncture for depression.

1.1.31. Wang 2008 ☆

Wang L, Sun DW, Zou W, Zhang JY. [Systematic evaluation of therapeutic effect and safety of acupuncture for treatment of depression]. Zhongguo Zhen Jiu. 2008; 28(5):381-6. [160799]

Objectives To assess the therapeutic effect of acupuncture on depression.
Methods A systematic evaluation of all relevant randomized controlled trials (RCT) about acupuncture and moxibustion treatment of depression was carried out by the study methods of evidence-based medicine. The data were statistically analyzed with a special analysis software RevMan 4.2.
Results Fourteen papers of RCT met the enrolled criteria. Four of the trials used double-blind method. Meta-analysis indicated that the effective rate was no significant difference between the acupuncture treatment and medication, and acupuncture treatment is better than Amitriptyline in improvement of HAMD scores, but no significant differences as compared with other drugs.
Conclusions Both acupuncture and medication possibly are effective for depression with good safety. However, because of lower methodological quality of the trials, this conclusion needs further be confirmed.

1.1.32. Sun 2008 ☆

Sun Yan-Li, Chen Shuang-Bai, Gao Yi, Xiong Jun. [Acupuncture versus Western Medicine for Depression in China: A Systematic Review ]. Chinese Journal of Evidence-Based Medicine. 2008; 8(5):340-5. [100365].

Objectives To assess the efficacy and safety of acupuncture versus western medicine in the treatment of depression neurosis.
Methods Randomized controlled trials (RCTs) involving acupuncture versus western medicine in the treatment of depression neurosis were identified from CBM (1978 to 2009),VIP (1989 to 2009),WANFANG Database (1998 to 2009), CNKI (1979 to 2009), PubMed (1966 to 2009), EMbase (1980 to 2009), and The Cochrane Library (Issue 4,2008). We also hand searched relevant journals from Tianjin University of Traditional Chinese Medicine. Data were extracted and evaluated by two reviewers independently with a specially designed extraction form. The Cochrane Collaboration’s RevMan 5.0.2 software was used for data analyses.
Results A total of 9 trials involving 903 patients were included. Meta-analyses showed that the total effective rate in the acupuncture group was similar when compared with Dailixin (RR= 1.01, 95%CI 0.82 to 1.23) on 20 d, fluoxetine (RR= 1.06, 95%CI 0.82 to 1.37) at week 8, but showing difference between acupuncture and fluoxetine (RR= 1.15, 95CI 1.07 to 1.22) at week 12. As for the HAMD score, no significant difference was noted between acupuncture and Dailixin (WMD= 0.45, 95%CI – 2.47 to 3.37) at 20 d, or amitriptyline at week 6, or fluoxetine on 30 d, and weeks 4, 8, 12; there was a difference between acupuncture and amitriptyline observed at week 1 (WMD= – 2.67, 95%CI – 4.38 to – 0.96) and week 2 (WMD= – 2.18, 95%CI – to – 1.08). In terms of the SDS scores, significant difference was found between acupuncture and fluoxetine (WMD= – 4.26, 95%CI – 6.67 to – 1.85) at week 6, but no difference at week 4 and 12. Four trials reported adverse events. One trial found that no adverse events existed in acupuncture according with TESS score, contrasting with thirst, constipation, vision vague, shimmy, fast heart rate, and some change in liver function and cardiogram in amitriptyline group.Two trials reported very low score in acupuncture showing difference when compared with the drugs. And one trial described that four people had stomach and intestinal tract disorders. While no adverse reactions happened in the acupuncture group.
Conclusions Acupuncture is not inferior to western medicine, and it is worth noting that acupuncture is associated with few adverse reactions. Further large-scale trials are required to define the role of acupuncture in the treatment of depression neurosis.

1.1.33. Wang H 2008 ☆

Wang Hao et al. Is acupuncture beneficial in depression: a meta-analysis of 8 randomised controlled trials? J Affect Disord. 2008;111(2-3):125-34.[149267].

Purpose This updated meta-analysis was conducted to more precisely assess the beneficial effect of acupuncture in depression therapy.
Methods The following databases were searched: MEDLINE, EMBASE, BIOSIS, Cochrane Central Register of Controlled Trials, and Chinese Scientific Journal Database. The following terms were used: acupuncture, acupressure, depression, depressive disorder, clinical trial, and randomized controlled trial.
Results Eight small-randomized controlled trials comparing 477 subjects were included in the meta-analysis. Our results confirmed that acupuncture could significantly reduce the severity of depression, which was indicated by decreased scores of Hamilton rating scale for depression (HAMD) or Beck Depression Inventory (BDI). The pooled standardized mean difference of the 'Improvement of depression' was -0.65 (95% CI -1.18, -0.11; P=0.02) by random effect model. However, no significant effect of active acupuncture was found on the response rate (RR 1.32, 95% CI 0.83 to 2.10; P=0.25) and remission rate (RR 1.30, 95% CI 0.57 to 2.95; P=0.53).
Conclusion Although this meta-analysis might be discounted due to the low quality of individual trials, it supported that acupuncture was an effective treatment that could significantly reduce the severity of disease in the patients with depression.

1.1.34. Leo 2007 Ø

Leo RJ, Ligot JS JR. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord. 2007;97(1-3):13-22. [141362].

Background Acupuncture has become a popular complementary and alternative treatment approach. This review examined the randomized controlled trials (RCTs) examining the effects of acupuncture treatment of depression.
MethodsRCTs of the treatment of depression with acupuncture were located using MEDLINE, Allied and Complementary Medicine and the Cochrane Central Register of Controlled Trials. The methodology of RCTs was assessed using the Jadad criteria, and elements of research design, i.e., randomization, blinding, assessment of attrition rates, were quantified for systematic comparisons among studies.
Results Among the 9 RCTs examined, five were deemed to be of low quality based upon Jadad criteria. The odds ratios derived from comparing acupuncture with control conditions within the RCTs suggests some evidence for the utility of acupuncture in depression. General trends suggest that acupuncture modalities were as effective as antidepressants employed for treatment of depression in the limited studies available for comparison. However, placebo acupuncture treatment was often no different from intended verum acupuncture. LIMITATIONS: The RCTs extracted were limited by small sample sizes, imprecise enrollment criteria, problems with randomization, blinding, brief duration of study and lack of longitudinal follow-up.
ConclusionsDespite the findings that the odds ratios of existing literature suggest a role for acupuncture in the treatment of depression, the evidence thus far is inconclusive. However, efforts are being made to standardize complementary approaches to treat depression, and further systematized research into their use is warranted

1.1.35. Thachil 2007 Ø

Thachil AF, Mohan R, Bhugra D. The Evidence Base of Complementary and Alternative Therapies in Depression. J Affect Disord. 2007.97(1-3):23-35. [141373].

Objectives Depression is one of the leading indications for using Complementary and Alternative Medicine (CAM). This paper reviews the evidence of efficacy of different types of CAM in depression with the aim of identifying the highest level of evidence.
Methods We conducted literature searches restricted to the English language for studies on CAM as monotherapy in depression. All papers were reviewed by two researchers and the evidence was ranked according to a widely referenced hierarchy of evidence
Results 19 papers formed the final review. We found Grade 1 evidence on the use of St. John's wort, Tryptophan/5-Hydroxytryptophan, S-adenosyl methionine, Folate, Inositol, Acupuncture and Exercise in Depressive disorders, none of which was conclusively positive. We found RCTs at the Grade 2 level on the use of Saffron (Herbal medicine), Complex Homoeopathy and Relaxation training in Depressive disorders, all of which showed inconclusive results. Other RCTs yielded unequivocally negative results. Studies below this level yielded inconclusive or negative results. LIMITATIONS: Searches were restricted to the English language. Our list of CAM approaches may not have been comprehensive. We excluded studies on the use of CAM as an adjunctive treatment and this review aimed to identify only the highest level of evidence.
Conclusions None of the CAM studies show evidence of efficacy in depression according to the hierarchy of evidence. The RCT model and the principles underlying many types of CAM are dissonant, making its application in the evaluation of those types of CAM difficult. The hierarchy of evidence we used has limited utility in grading trials of CAM.
Acupuncture the evidence was insufficient to determine the efficacy of acupuncture vs. medication due to the poor methodological quality and reporting of these trials. There was insufficient data to demonstrate whether acupuncture is more effective than a wait-list control, non-specific or sham acupuncture control, or whether acupuncture plus medication is more effective than acupuncture plus placebo.

1.1.36. Mukaino 2005 Ø

Mukaino Y, Park JB, White A, Ernst E. The effectiveness of acupuncture for depression a systematic review of randomised controlled trials. Acupuncture in Medicine. 2005. 23(2):70. [140263].

ObjectiveTo summarise the existing evidence on acupuncture as a therapy for depression.
Methods RCTs were included, in which either manual acupuncture or electroacupuncture was compared with any control procedure in subjects with depression. Data were extracted independently by two authors. The methodological quality was assessed. Pre and post means and SDs for depression specific measures were extracted, when available, for meta-analysis.
Results Seven randomised comparative trials involving 509 patients were included. The evidence is inconsistent on whether manual acupuncture is superior to sham, and suggests that acupuncture was not superior to waiting list. Evidence suggests that the effect of electroacupuncture may not be significantly different from antidepressant medication, weighted mean difference -0.43(95% CI -5.61 to 4.76). There is inconclusive evidence on whether acupuncture has an additive effect when given as an adjunct to antidepressant drugs.
Conclusion The evidence from controlled trials is insufficient to conclude whether acupuncture is an effective treatment for depression, but justifies further trials of electroacupuncture.

1.1.37. Smith 2005 Ø

Smith C, Hay P. Acupuncture for depression. Cochrane Database Syst Rev. 2005. (2):CD004046. [136183].

BackgroundThere 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.
ObjectivesTo examine the efficacy and adverse effects of acupuncture for depression.
Methods Search strategy: The following databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL) MEDLINE (1966 to Sept 2003) EMBASE (1980 to Sept 2003) PSYCINFO (1874 to Sept 2003) the Database of Abstracts of Reviews of Effectiveness (DARE) CISCOM, CINAHL (January 1980 to Sept 2003). 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 subjects 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), or the International Classification of Disease (ICD). Data collection and analysis: Meta analysis was performed using relative risk for dichotomous outcomes and weighted 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 vs no remission.
Main resultsSeven trials comprising 517 subjects met the inclusion criteria. Five trials (409 subjects) included a comparison between acupuncture and medication. Two other trials compared acupuncture with a wait list control or sham acupuncture. Subjects generally had mild to moderate depression. There was no evidence that medication was better than acupuncture in reducing the severity of depression (WMD 0.53, 95%CI -1.42 to 2.47), or in improving depression, defined as remission versus no remission (RR1.2, 95%CI 0.94 to 1.51).
Authors' conclusionsThere is insufficient evidence to determine the efficacy of acupuncture compared to medication, or to wait list control or sham acupuncture, in the management of depression. Scientific study design was poor and the number of people studied was small.

1.1.38. Ernst 1998 Ø

Ernst E et al. Complementary Therapies for Depression: An Overview. Arch Gen Psychiatry. 1998;55(11):1026-32. [58721].

Objectives Depression is one of the most common reasons for using complementary and alternative therapies. The aim of this article is to provide an overview of the evidence available on the treatment of depression with complementary therapies.
Methods Systematic literature searches were performed using several databases, reference list searching, and inquiry to colleagues.
Results Data extraction followed a predefined protocol. The amount of rigorous scientific data to support the efficacy of complementary therapies in the treatment of depression is extremely limited. The areas with the most evidence for beneficial effects are exercise, herbal therapy (Hypericum perforatum), and, to a lesser extent, acupuncture and relaxation therapies.
Conclusions There is a need for further research involving randomized controlled trials into the efficacy of complementary and alternative therapies in the treatment of depression.

1.2. Special Acupuncture Techniques

1.2.1. Combined with antidepressants

1.2.1.1. Chan YY 2015 ☆☆

Chan YY, Lo WY, Yang SN, Chen YH, Lin JG. The benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis. J Affect Disord. 2015;176C:106-117.[177239].

Purpose Acupuncture, one of the most popular complementary therapies, is best known for its ability to provide pain relief. Accumulating evidence suggests that acupuncture may also be beneficial in depression, although its effectiveness remains uncertain in this condition.
Methods We conducted a meta-analysis of randomized trials in which the effects of acupuncture combined with antidepressant medications were compared with those of antidepressant medications alone in adults with a diagnosed depressive disorder.
Results Thirteen randomized controlled trials involving 1046 subjects were included in the meta-analysis . Our results confirmed that the pooled standardized mean difference of the 'endpoint scores of the 17-item Hamilton rating scale for depression' was -3.74 (95% CI, -4.77 to -2.70, p<0.001) in week 1 and -2.52 (95% CI, -4.12 to -0.92; p<0.01) in week 6, indicating a significant difference in favor of acupuncture combined with selective serotonin reuptake inhibitors (SSRIs). Moreover, therapeutic response rates were statistically significantly different between the two groups (risk ratio [RR], 1.23; 95% CI, 1.10 to 1.39; p<0.001; I2=68%) in favor of the combined treatment group.
Conclusion This systematic review and meta-analysis suggest that acupuncture combined with antidepressant medication is effective, has an early onset of action, safe and well-tolerated over the first 6-week treatment period. Moreover, this treatment combination appears to result in greater therapeutic efficacy than SSRI therapy alone.
1.2.1.2. Zhang 2015 (electroacupuncture + SSRIs) ☆☆

Zhang Y, Qu SS, Zhang JP, Sun YL, Liu WL, Xie L, Huang Y, Chen JQ. Rapid onset of the effects of combined selective serotonin reuptake inhibitors and electroacupuncture on primary depression: a meta-analysis. J Altern Complement Med. 2016;22(1):1-8. [185148].

ObjectivesTo evaluate the efficacy and safety of combined selective serotonin reuptake inhibitors (SSRIs) and electroacupuncture therapies for the early treatment of primary depression.
Methods Randomized controlled trials (RCTs) were analyzed to compare therapy combining SSRIs and electroacupuncture to SSRI therapy alone. The RCTs were identified by searching, among others, PubMed, the Cochrane Library, the Chinese National Knowledge Infrastructure, the Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, and the Chinese Biological Medical Literature Database. Scores from Self-Rated Depression Scale (SDS), the Hamilton Depression Scale (HAMD), the Side Effect Rating Scale (SERS), and the Treatment Emergent Symptom Scale (TESS) were analyzed and coded by two independent investigators and used to evaluate the safety and efficacy of treatment. Statistical analyses were performed using RevMan 5.2 software.
ResultsSix RCTs were analyzed. The meta-analysis revealed that the combined therapy of SSRIs and electroacupuncture were associated with superior scores on the HAMD, SDS, and SERS measures compared with SSRIs alone after 1-4 weeks of treatment: HAMD scores, mean difference (MD)1 week, 2.32 (95% confidence interval [CI]1 week, 1.47-3.16, p1 week<0.00001); MD2 weeks , 2.65 (95% CI2 weeks, 1.81- 3.50, p2 weeks<0.00001); MD4 weeks, 2.70 (95% CI4 weeks, 1.90-3.51, p4 weeks<0.00001); SDS scores: MD1 week, 3.13 (95% CI1 week, 1.22-5.03, p1 week = 0.001); MD2 weeks, 4.05 (95% CI2 weeks, 0.22-7.87, p2 weeks = 0.04); MD4 weeks, 5.02 (95% CI4 weeks, 1.61-8.43, p4 weeks = 0.004); SERS scores: MD2 weeks, 2.20 (95% CI2 weeks, 1.43-2.96, p2 weeks<0.00001); MD4 weeks, 2.12 (95% CI4 weeks, 1.42-2.83, p4 weeks<0.00001). However, two of the aforementioned outcomes were rated as medium quality because of heterogeneity, as assessed using the Grading of Recommendations Assessment, Development and Evaluation system.
Conclusions The available evidence suggests that the early treatment of primary depression using both SSRI and electroacupuncture therapies is more efficient than treatments with SSRIs alone and leads to a better and earlier control of depressive symptoms.

1.2.2. Electroacupuncture

1.2.2.1. Zhang 2022

Zhang Z, Cai X, Liang Y, Zhang R, Liu X, Lu L, Huang Y. Electroacupuncture as a rapid-onset and safer complementary therapy for depression: A systematic review and meta-analysis. Front Psychiatry. 2023 Jan 6;13:1012606. https://doi.org/10.3389/fpsyt.2022.1012606.

BackgroundElectroacupuncture (EA) is a promising therapy for depression. However, a comprehensive review of EA for depression is needed.
MethodsWe conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA 2020) guidelines to evaluate the efficacy and safety of EA for depression. Potentially relevant trials and reviews were searched in MEDLINE, EMBASE, PsycINFO, and CENTRAL from inception to March 2022. EA alone and combined with other therapy were eligible for inclusion. The severity of depression during and after treatment and the number of adverse events were assessed as outcomes. Risk of bias (ROB) evaluation, subgroup analysis, sensitivity analysis, reporting bias assessment, and GRADE system evaluation were also conducted.
ResultsThirty-four trials were included. The overall ROB was medium. Low-quality evidence showed that the efficacy of EA was not less than that of antidepressants [EA + selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs)] and manual acupuncture (MA). EA and EA + SSRIs had better efficacy than SSRIs alone in decreasing the severity of depression during the early treatment. Moderate-quality evidence also showed that EA and EA + SSRIs were safer than SSRIs alone. Sensitivity analysis was mostly not feasible. Major publication bias was unlikely.
ConclusionThese results indicate that the efficacy of EA is not less than that of antidepressants and MA. Moreover, EA and EA + SSRI treatments show a more rapid onset and greater safety than SSRIs. More high-quality trials are needed for further confirmation.
1.2.2.2. Xu 2008 ☆

Xu Xu-Dong, Wu Yu-Ju. [Meta-analysis of effects of electric acupuncture on depression]. Journal of Clinical Psychiatry. 2008;2:111-112. [186991].

Objectives To analyse the effects of electric acupuncture on depression by Meta-analysis.
Methods To collect the related clinical comparison studies and evaluated them by Meta-analysis.
Results 29 studies were enrolled in the study. There was no significant difference in efficacy between electric acupuncture treatment and antidepressant treatment, whereas obvious difference was found between electric acupuncture combined drug treatment and drug treatment only.
Conclusions Antidepressant treatment shows an equivalent efficacy compared with electric acupuncture treatment. However, electric acupuncture combined antidepressant treatment has a better efficacy than antidepressant treatment only.

1.2.3. Clinical Emotional Freedom Techniques (EFT)

1.2.3.1. Nelms 2016

Nelms JA, Castel L. A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials of Clinical Emotional Freedom Techniques (EFT) for the Treatment of Depression. Explore (NY). 2016;8307(16):30106-9. [189377].

Background Among a group of therapies collectively known as energy psychology (EP), emotional freedom techniques (EFT) is the most widely practiced. Clinical EFT is an evidence-based practice combining elements of cognitive and exposure therapies with the manual stimulation of acupuncture points (acupoints). Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of outcomes after clinical EFT treatment in reducing depression.
MethodsAll studies (2005-2015) evaluating EFT for sufferers of depression were identified by electronic search; these included both outcome studies and randomized controlled trials (RCTs). Our focus was depressive symptoms as measured by a variety of psychometric questionnaires and scales. We used meta-analysis to calculate effect sizes at three time points including posttest, follow-ups less than 90 days, and follow-ups more than 90 days.
ResultsIn total, 20 studies were qualified for inclusion, 12 RCTs and 8 outcome studies. The number of participants treated with EFT included N = 461 in outcome studies and N = 398 in RCTs. Clinical EFT showed a large effect size in the treatment of depression in RCTs. At posttest, Cohen׳s d for RCTs was 1.85 and for outcome studies was 0.70. Effect sizes for follow-ups less than 90 days were 1.21, and for ≥ 90 days were 1.11. EFT were more efficacious than diaphragmatic breathing (DB) and supportive interview (SI) in posttest measurements (P = .06 versus DB, P < .001 versus SI), and sleep hygiene education (SHE) at follow-up (P = .036). No significant treatment effect difference between EFT and eye movement desensitization and reprocessing (EMDR) was found. EFT were superior to treatment as usual (TAU), and efficacious in treatment time frames ranging from 1 to 10 sessions. The mean of symptom reductions across all studies was -41%.
ConclusionsThe results show that Clinical EFT were highly effective in reducing depressive symptoms in a variety of populations and settings. EFT were equal or superior to TAU and other active treatment controls. The posttest effect size for EFT (d = 1.31) was larger than that measured in meta-analyses of antidepressant drug trials and psychotherapy studies. EFT produced large treatment effects whether delivered in group or individual format, and participants maintained their gains over time. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of depression improvement subsequent to EFT treatment.

1.3. Special Clinical Forms

1.3.1. Subthreshold Depression

1.3.1.1. Jiang 2021

Jiang X, Luo Y, Chen Y, Yan J, Xia Y, Yao L, Wang X, He S, Wang F, Wang T, Chen Y. Comparative Efficacy of Multiple Therapies for the Treatment of Patients With Subthreshold Depression: A Systematic Review and Network Meta-Analysis. Front Behav Neurosci. 2021. [222724]. https://doi.org/10.3389/fnbeh.2021.755547

Background Subthreshold depression (SD) is considered to be the precursor stage of major depression, which is correlated with functional impairment and increased suicide rate. Although there are multiple therapies for the treatment of SD, the comparison and efficacy of various methods has yet to be evaluated. This study aimed to evaluate the efficacy of different therapies by performing a Bayesian network meta-analysis.
Methods We searched eight databases on April 3, 2021. Center for Epidemiologic Studies Depression Scale (CES-D), Beck Depression Inventory scale (BDI), the Patient Health Questionnaire-9 (PHQ-9), and the Kessler Screening Scale for Psychological Distress (K-6) were used as efficacy outcomes. This Bayesian network meta-analysis used a fixed-effects model.
FindingsTwenty-one randomized controlled trials involving 5,048 participants were included in this study. The results suggested that electroacupuncture (MD -12.00, 95% CrI -15.00, -10.00), conventional acupuncture plus wheat-grain moxibustion (MD -9.70, 95% CrI -14.00, -5.30), and the Chinese traditional peripateticism pill plus group counseling (MD -9.00, 95% CrI -11.00, -6.70) had better efficacy than the control group (CG) in improving CES-D. For BDI outcome, bright light therapy (MD -9.70, 95% CrI -13.00, -6.00), behavioral activation program (MD -5.70, 95% CrI -6.10, -5.40), and dim light therapy (MD -6.30, 95% CrI -10.00, -2.20) were better than the CG. Tai chi (MD -3.00, 95% CrI -4.00, -2.00) was better than CG for PHQ-9 outcomes. Telephone-based cognitive behavioral treatment (MD -2.50 95% CrI -2.70, -2.30) was better than the CG for K-6 scores.
ConclusionOur results suggest that electroacupuncture or bright light therapy appear to be the better choices in the treatment of SD. This study provide new insights into clinical treatment selection and may aid the development of guidelines for the management of SD..
1.3.2.1. You 2021

You J, Li H, Xie D, Chen R, Chen M. Acupuncture for Chronic Pain-Related Depression: A Systematic Review and Meta-Analysis. Pain Res Manag. 2021. [217543]. doi

ObjectiveThe aim of this systematic review was to summarize and evaluate the existing evidence on the effectiveness and safety of acupuncture in relieving chronic pain-related depression (CPRD).
Methods We searched seven online databases to identify eligible randomized controlled trials (RCTs) of acupuncture for CPRD published before September 2020. We included studies that used acupuncture as the intervention group, with or without a control group, and the control group was treated with conventional drugs. Meta-analysis was performed using RevMan 5.3 software. For outcomes, assessments were performed using the Hamilton Depression Scale (HAMD), Visual Analogue Scale (VAS), and adverse events.
Results Eight studies involving 636 participants were identified and included in the meta-analysis. The results showed that single acupuncture treatment and drug treatment have the same effect in improving the HAMD score (MD = -0.14, 95% CI = [-0.88, 0.59], P = 0.71) and alleviating the VAS score (MD = -0.42, 95% CI = [-1.10, -0.27], P = 0.23), but acupuncture treatment is safer (OR = 0.03, 95% CI = [0.01, 0.21], P = 0.0003). In addition, acupuncture combined with drugs (control group) is more beneficial than single-drug treatment in improving the HAMD score (MD = -2.95, 95% CI = [-3.55, -2.36], P < 0.00001) and alleviating the VAS score (MD = -1.06, 95% CI = [-1.65, -0.47], P = 0.0004).
Conclusion Acupuncture is an effective and safe treatment for CPRD, and acupuncture combined with drug therapy is more effective than single-drug therapy. Nevertheless, the conclusions were limited due to the low quality and a small number of included studies.

1.3.3. Cardiovascular disease complicated with depression

1.3.3.1. Lu 2022

Lu L, He W, Guan D, Jiang Y, Hu G, Ma F, Chen L. Acupuncture in treating cardiovascular disease complicated with depression: A systematic review and meta-analysis. Front Psychiatry. 2022 Dec 1;13:1051324. https://doi.org/10.3389/fpsyt.2022.105132

Background Depression is a serious risk for cardiovascular disease (CVD). Improving depression can alleviate cardiac symptoms and improve quality of life. Studies have shown that acupuncture has a positive effect on depression and CVD. This systematic review and meta-analysis will evaluate the efficacy and safety of acupuncture in the treatment of depression complicated with CVD.
Methods We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and China Biomedical Literature databases. Randomized controlled trials of acupuncture vs. standard care or sham acupuncture or antidepressants were included. The retrieval time is from database construction to 07 April 2022. We used the “risk of bias” tool of Cochrane Collaboration, and the Review Manager (RevMan.) Version 5.4.1 for statistics analysis. Primary outcomes included Hamilton scale for depression (HAMD), self-rating depression scale (SDS), and the effective rate of depression. Secondary outcomes included frequency of angina pectoris and visual analogue scale (VAS) scores for angina pain.
ResultsA total of 2,366 studies were screened based on the search strategy. Twelve eligible studies with a total of 1,203 participants have been identified. The result showed that acupuncture reduced the HAMD score [weighted mean difference (WMD): -3.23; 95% confidence interval (CI): -5.38 to -1.09; P = 0.003] and the SDS score (WMD: -1.85; 95% CI: -2.14 to -1.56; P < 0.00001) in patients with depression complicated with CVD. Acupuncture also improved the effective rate of depression (risk ratio: 1.15; 95% CI: 1.03 to 1.29; P = 0.01). The result also showed that acupuncture reduced the attack frequency of angina pectoris (WMD: -4.54; 95% CI: -5.96 to -3.11; P < 0.00001) and the VAS score for angina pain (WMD: -0.72; 95% CI: -1.06 to -0.38; P < 0.0001). This article reviewed the significant advantages of acupuncture for depression and the superiority of acupuncture over no-intervention therapy, antidepressant therapy, and psychotherapy in reducing angina frequency and pain intensity in patients with CVD.
ConclusionThis systematic review suggested that acupuncture was a good complementary and alternative therapy for CVD complicated with depression. Considering the limitations of the included research literature, it is still necessary to perform multi-center, large-sample, and double-blind high-quality studies to provide higher-level evidence in the later stage.

1.3.4. Depression Among Students

1.3.4.1. Li 2023

Li FB, Lu P, Wu HT, Wang MH, Wang JD. Effects of Music, Massage, Exercise, or Acupuncture in the Treatment of Depression Among College Students: A Network Meta-Analysis. Neuropsychiatr Dis Treat. 2023 Aug 1;19:1725-1739. https://doi.org/10.2147/NDT.S416643

Objective To assess the therapeutic impacts of exercise, massage, and music interventions on college students experiencing depression by employing a mesh meta-analysis approach. This research intends to offer valuable insights to aid in the development of non-pharmaceutical treatment strategies for depression.
Methods We conducted a thorough search across various databases including Cochrane, PubMed, Embase, Web of Science, CNKI, and Wanfang to explore the effects of music, massage, aerobic exercise, fitness Qigong, yoga, tai chi, ball games, strength training, dance, whole body vibration training, and high-intensity interval training on the treatment of depression in college students. The search period was from January 1, 2023, which marks the establishment of each database. Subsequently, a mesh meta-analysis was performed using the “Stata 15.1” software, incorporating outcome indicators from 24 included literature comprising a total of 1458 patients.
Results Based on the ranking of the optimal intervention effects of various non-pharmaceutical methods, the order, from highest to lowest probability, was as follows: high-intensity interval training (96%), yoga (94.90%), dance (78.30%), music (73.30%), ball games (62.50%), strength training (51.70%), aerobic training (45.30%), tai chi (35.40%), vibration training (27.30%), massage (20.10%), qigong (14.30%), and no intervention (1.00%). This ranking aligns closely with the findings obtained from pairwise comparisons between different interventions.
Conclusion High-intensity interval training is likely to yield the most effective therapeutic results for college students with depression. In the pairwise comparison of different interventions, High-intensity interval training is also better than most interventions. However, to establish its intervention effect more conclusively, further validation through additional high-quality randomized controlled trials is necessary.

1.3.5. Late-life depression

1.3.5.1. Cai 2023

Cai W, Wei XF, Zhang JR, Hu C, Shen WD. Does acupuncture treatment have satisfactory clinical efficacy for late-life depression? A systematic review and meta-analysis. Geriatr Nurs. 2023 May-Jun;51:215-221. https://doi.org/10.1016/j.gerinurse.2023.03.008

Objective This systematic review and meta-analysis aimed to assess the clinical efficacy of acupuncture in late-life depression (LLD).
Methods A comprehensive search of seven electronic databases was conducted from inception to November 2022, including the Cochrane Library, PubMed, Embase, CNKI, VIP, CBM and the Wan Fang database. All data analysis were conducted by Revman 5.3.
Results A total of nine RCTs involving 603 participants were included. The meta-analysis results showed that acupuncture combined with antidepressants significantly reduced HAMD scores (MD, -3.69 [95% CI, -5.11 to -2.27], I2 =74%) and a significantly higher cure rate (RR, 1.11 [95% CI, 1.01 to 1.22], I2 = 0%) compared with antidepressants alone. However, no significant difference was found between acupuncture and antidepressants in reducing HAMD scores and improving clinical outcomes.
Conclusions Acupuncture combined or not combined with antidepressants is an effective and safe treatment for LLD.

1.3.6. Poststroke Depression

1.3.7. Diabetes and depression

1.3.8. Anxiety and Depression in Cancer Patients

1.3.9. Pregnancy and Postpartum Depression

1.3.10. Perimenopausal Depression

1.3.11. Depression during IVF

1.3.13.1. Hsu 2023

Hsu WT, Hsu CM, Hung SC, Hung SY. Acupuncture Improves Sleep Disorders and Depression among Patients with Parkinson's Disease: A Meta-Analysis. Healthcare (Basel). 2023 Jul 17;11(14):2042. https://doi.org/10.3390/healthcare11142042

Backgound Parkinson's disease (PD) is associated with a range of non-motor symptoms that lack effective treatments. Acupuncture is a popular alternative therapy for PD patients that has been shown to improve motor symptoms. However, the efficacy of acupuncture in treating non-motor symptoms has remained controversial. The goal of our study was to systematically assess the existing evidence for acupuncture's efficacy in treating PD non-motor symptoms of sleep disorders, depression, anxiety, and fatigue.
Method We conducted a meta-analysis of clinical trials by searching Pubmed, Embase, CINAHL, and Web of Science as electronic databases to evaluate acupuncture treatment for PD non-motor symptoms. Thirteen clinical trials met our inclusion criteria, and their methodological quality was assessed using the modified Jadad scale, indicating a moderate overall quality.
Results Our results showed that acupuncture improved PD-related sleep disorders and depression but had no effect on anxiety and fatigue. Our meta-analysis suggests that acupuncture can be used as a complementary treatment for sleep disturbances and depression in PD patients and may exhibit a dual therapeutic effect on motor and non-motor symptoms. However, further well-designed clinical trials with larger sample sizes are needed to confirm these findings.
Conclusion Overall, our study highlights the potential of acupuncture as a viable complementary therapy for the treatment of PD non-motor symptoms of sleep disorders and depression, which can improve the quality of life of PD patients.

1.4. Specific outcome

1.4.1. Suicidal Behavior

1.4.1.1. Kwon 2023

Kwon CY, Lee B. The Effectiveness and Safety of Acupuncture on Suicidal Behavior: A Systematic Review. Healthcare (Basel). 2023 Mar 27;11(7):955. https://doi.org/10.3390/healthcare11070955.

Backgound In situations where death by suicide is a major global issue and effective prevention and management approaches are lacking, acupuncture improves some risk factors for suicide, including depression, and it has been used for a long time in clinical settings. Herein, we aimed to assess the effectiveness and safety of acupuncture in the treatment of suicidal behaviors.
Methods Fourteen electronic databases were searched for studies published up to 7 September 2022. Original interventional studies of acupuncture in suicide prevention were included. The primary outcome was the validated measure of suicidal ideation. The risk of bias in the included studies was assessed using an appropriate assessment tool. Due to the heterogeneity of the included studies, only qualitative analyses were conducted.
Results Eight studies on manual acupuncture (50%), electro-acupuncture (37.5%), and acupressure (12.5%) were included. In particular, three studies (37.5%) used the National Acupuncture Detoxification Association protocol to stimulate the bilateral sympathetic, Shenmen, kidney, liver, and lung auricular points. Acupuncture was effective in direct and indirect outcomes related to suicidal behavior, not only for participants with suicidal behavior, but also for those with other conditions, including depression. A decrease in salivary cortisol was the only biological indicator of acupuncture in patients with suicidal ideation. However, the methodological quality of the included studies was not optimal.
Conclusion In conclusion, acupuncture may reduce the risk of suicidal behavior in clinical and non-clinical populations. Owing to clinical heterogeneity, low methodological quality, and the small number of included studies, further high-quality studies should assess the effectiveness of acupuncture.

1.4.2. Dose-effect

1.4.2.1. Xu 2022

Xu G, Lei H, Huang L, Xiao Q, Huang B, Zhou Z, Tian H, Huang F, Liu Y, Zhao L, Li X, Liang F. The dose-effect association between acupuncture sessions and its effects on major depressive disorder: A meta-regression of randomized controlled trials. J Affect Disord. 2022 Aug 1;310:318-327. https://doi.org/10.1016/j.jad.2022.04.155

BackgroundThe benefits of acupuncture on Major depressive disorder (MDD) have been well established in previous studies. However, uncertainty exists regarding the dose-effect relationship between acupuncture and MDD. This study aims to explore the association between acupuncture and its effects on MDD based on previously published data.
Methods Nine databases were searched from inception until 10th September 2021. Randomized controlled trials that compared acupuncture with sham acupuncture, or anti-depressants, were included. The data extraction, and assessing the data quality and risk of bias completed by two researcher, respectively. A non-linear meta-regression approach with restricted cubic spline was used to investigate the dose-effect relationship between acupuncture sessions and their effects on the Hamilton rating scale for depression (HAMD) score.
Results Of the 20,835 citations screened, 62 studies (2269 patients of MDD) were included. The dose-effect meta-analysis suggested that acupuncture session was associated with a decline in HAMD scores. Overall, an increase in the number of acupuncture sessions received was associated with symptom improvement in MDD patients. After 8 acupuncture sessions, the HAMD score decreased from 17.68 (95% CI: -11.81, -4.80) to 8.30 (95% CI: 14.23-21.13). After 24 acupuncture sessions, a decrease in HAMD scores was observed in 51% of cases (95% CI: 48% to 54%). After 36 acupuncture sessions, the effect of improvement in HAMD scores peaked at 66% of cases (95% CI: 59% to 72%).
Conclusions A dose-effect relationship was found between the number of acupuncture sessions and HAMD scores. 36 acupuncture sessions were associated with optimal clinical response.

1.4.3. Ye 2019 (Neuroscience Evidence)

Ye J, Cheung WM, Tsang HWH. The Neuroscience of Nonpharmacological Traditional Chinese Therapy (NTCT) for Major Depressive Disorder: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2019:13P. [199926].

BackgroundDepression is a common disease affecting a large number of people across the world. Many researchers have focused on treatment for depression based on Western scientific approaches, but research based on traditional Chinese medicine (TCM) interventions, studying its clinical effectiveness and the underlying mechanisms involved, has been limited. The aim of this review is to conduct a pioneering systematic review with meta-analysis of existing studies that investigate the neuroscience basis of nonpharmacological traditional Chinese therapy (NTCT).
Methods Both English (Pubmed, Embase, Scopus, SPORTDiscus, PsycINFO) and Chinese (China National Knowledge Infrastructure (CNKI)) databases were searched from inception to October 2018. The effects of NTCT on major depressive disorder, brain activity, and neurophysiological biomarker related outcomes were extracted. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. The effect size of each study was reported by the mean difference of change scores.
Results Six of twelve eligible studies showed that there was a significant improvement in favor of acupuncture in depressive symptoms (SMD -0.69, 95% CI -1.09 to -0.28, p=0.002, I 2 = 73%, p< 0.0008). Based on the available evidence, NTCT including acupuncture, Qigong, and Tai Chi was found to possibly improve brain metabolites, brain activity, and immune and endocrine systems in patients with major depressive disorder.
ConclusionsAcupuncture could effectively relieve depressive syndromes. The clinical effects of acupuncture might be attributable to their influence on three proposed pathways, namely, the hypothalamic-pituitary-adrenal (HPA) axis, the locus coeruleus (LC)-immunity pathway, and the negative feedback loop of the hippocampus. Nevertheless, conclusions are limited due to the small number of studies included and the low-quality of the study designs. In the future, a cross-sectional study is needed to test the proposed plausible pathways.

2. Overviews of Systematic Reviews

2.1. Li 2020

Li M, Niu J, Yan P, Yao L, He W, Wang, Li H, Cao L, Li X, Shi X, Liu X, Yang K. The effectiveness and safety of acupuncture for depression: An overview of meta-analyses. Complement Ther Med. 2020. [209269]. doi

PurposeTo provide an overview of existing meta-analysis (MAs) on the efficacy and safety of acupuncture for depression, and assess the methodological quality and the strength of evidence of the included MAs.
MethodsWe searched MAs of randomized trials that have evaluated the effects of acupuncture on depression in three international and three Chinese databases from their inception until August 2019. The methodological quality of included MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the strength of evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We used the intra-class correlation coefficient (ICC) to assess reviewer agreement in the pre-experiment.
ResultsWe included 31 MAs and 59 RCTs. The results of included MAs were conflicting, our meta-analyses found that acupuncture may confer small benefit in reducing the severity of depression by end of treatment than no treatment/wait list/treatment as usual(SMD -0.74, 95% CI -1.06 to -0.41, eight trials, 624 participants), control acupuncture (invasive, non-invasive sham controls) (SMD 0.27, 95% CI -0.51 to -0.04, 20 trials, 1055 participants), antidepressants(Selective serotonin reuptake inhibitors (SSRI)/ Tetracyclic antidepressants(TCAs)) (SMD -0.28, 95% CI -0.46 to -0.10, 30 trials, 3068 participants), acupuncture plus antidepressants versus antidepressants(SSRI/TCAs) (SMD -0.99, 95% CI -1.37 to -0.61, 17 trials, 1110 participants). Subgroup analyses showed that there was no difference between electro-acupuncture and invasive control (P = 0.37), electro-acupuncture and non-invasive control (P = 0.90), manual acupuncture and Tetracyclic antidepressants (P = 0.57), electro-acupuncture and Tetracyclic antidepressants (P = 0.07). Six MAs concluded that acupuncture reduced the incidence of adverse events compared with antidepressants. The evaluation with AMSTAR-2 showed that the quality of included MAs was low or critically low. The results of the GRADE evaluation showed that the strength of evidence was low to very low for most outcomes.
Conclusions

2.1. Gao 2019

Gao Tao, Zheng Qianhua, Hou Tinghui et al. Acupuncture for depression: An overview of systematic reviews. European Journal of Integrative Medicine. 2019;28:1-13. [206389]. doi

Introduction As current evidence on the effectiveness of acupuncture for depression is inconsistent, this overview aims to summarize and critically evaluate the evidence of relevant systematic reviews (SRs).
Methods A comprehensive literature search was conducted using multiple databases for SRs on acupuncture for depression from their inception to December 2018. Two authors independently selected articles, collected data, and assessed the methodological and reporting quality of identified SRs according to revised Assessment of Multiple Systematic Reviews (AMASTAR 2) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), respectively.
Results Nine SRs were included in this overview. The items of AMSTAR 2 in most SRs were poorly reported, and only one SR achieved a decent overall rating and considered to be of moderate quality assessed by AMSTAR 2. A total of 7 SRs obtained a decent rating by PRISMA. No firm conclusions were made on the effectiveness of acupuncture for depression.
Conclusion The methodological and reporting quality of SRs on acupuncture for depression was suboptimal. In future studies, more efforts are needed to improve the quality of SRs in this area.

2.2. Ernst 2011

Ernst E, Lee MS, Choi TY.. Acupuncture for depression?: A systematic review of systematic reviews. Eval Health Prof. 2011;34(4):403-12. [70589].

BackgroundAcupuncture is often advocated as a treatment for depression, and several trials have tested its effectiveness. Their results are contradictory and even systematic reviews of these data do not arrive at uniform conclusions.
Objectives The aim of this review is to critically evaluate all systematic reviews of the subject with a view of assisting clinical decisions.
MethodsThirteen electronic databases were searched to identify all relevant articles. Data of these systematic reviews and the primary studies they included were extracted independently by the two authors according to predefined criteria.
ResultsEight systematic reviews including seventy-one primary studies were found. Five of the reviews arrived at positive conclusions and three did not. All the positive reviews and most of the positive primary studies originated from China. There are reasons to believe that these reviews are less than reliable.
Conclusions In conclusion, the effectiveness of acupuncture as a treatment of depression remains unproven and the authors' findings are consistent with acupuncture effects in depression being indistinguishable from placebo effects.

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

3.1. Department of Veterans Affairs Department of Defense (VA/DoD, USA) 2022 Ø

VA/DoD clinical practice guideline for the management of major depressive disorder. Department of Veterans Affairs Department of Defense. 2022:159P. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf

For patients with MDD, there is insufficient evidence to recommend for or against acupuncture as an adjunct.

3.2. National Institute for Health and Care Excellence (NICE, UK) 2022 Ø

Depression in adults: treatment and management National Institute for Health and Care Excellence (NICE). 2022;:103P. [223649]. URL

There was some evidence of effectiveness and cost effectiveness for the combination of acupuncture and antidepressants but the committee were aware this evidence was based on Chinese acupuncture which is different to Western acupuncture and so these results may not be applicable to the UK population, so the committee made a research recommendation on acupuncture and antidepressants.
Research recommendation : First-line treatment of more severe depression. What is the effectiveness and cost effectiveness of combination treatment with acupuncture and antidepressants in people with more severe depression in the UK?

3.3. University of Michigan Health System (UMHS, USA) 2021 ⊕

Ambulatory Unipolar Depression Guideline. University of Michigan Health System. 2021:68P. [216712]. URL

Consider acupuncture as an adjunctive treatment in mild to moderate depression (Second-line, Level of Evidence B).
Treatment for Major Depressive Disorder in Pregnancy: Mild to Moderate Major Depressive Disorder: acupuncture (3rd-line, Level of Evidence B). Severe Major Depressive Disorder: acupuncture (3rd-line, Level of Evidence D).
Treatment of Postpartum Depression during Breastfeeding: Severe Major Depressive Disorder: acupuncture 2nd-line, Level of Evidence B).

3.4. Ministry of Public Health of Qatar (MOPH, Qatar) 2020 Ø

The diagnosis & management of depression. National Clinical Guidelines. Ministry of Public Health of Qatar (MOPH). 2020;:39P. [219469]. URL

The following are not recommended to treat depression: … Acupuncture. [L1, RGB].

3.5. American Psychological Association (APA, USA) 2019 ⊕

Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. American Psychological Association. 2019:213P. [182784]. URL

If neither is acceptable or available, the panel suggests consideration of : Bright light therapy, Yoga, If considering adjunctive treatments, the panel suggests adding acupuncture to antidepressant medication (Conditional recommendation for use).
There is insufficient evidence to recommend : Acupuncture Monotherapy, Combination of second-generation antidepressant and acupuncture.

3.6. Malaysia Health Technology Assessment Section (MaHTAS, Malaysia) 2019 Ø

Malaysia Health Technology Assessment Section (MaHTAS). Management of major depressive disorder (second edition) . Ministry of Health (MoH). 2019:108p. [172322]. URL

There is insufficient evidence on the effectiveness and safety of acupuncture, omega-3 and folate in MDD.

3.7. Canadian Network for Mood and Anxiety Treatments (CANMAT, Canada) 2016 ⊕

Ravindran AV, Balneaves LG, Faulkner G, Ortiz A, McIntosh D, Morehouse R et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments. Can J Psychiatry. 2016;61(9):576-87. [52128].

Acupuncture is recommended as a third-line treatment, with Level 2 Evidence in the adjunctive treatment of mild to moderate MDD.

3.8. Institute for Clinical Systems Improvement (ICSI, USA) 2016 ⊕

Institute for Clinical Systems Improvement. Adult depression in primary care. Health care guideline. 17th edition. Bloomington: ICSI; 2016.

Il y a des preuves préliminaires prometteuses pour la luminothérapie, l’acupuncture, la relaxation progressive, la musicothérapie, la réduction du manque de sommeil, et l’exercice physique.

3.9. American College of Physicians (ACP, USA) 2016 ⊕

Qaseem A, Barry MJ, Kansagara D. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164(5):350-9. [176625].

(SGAs) : second-generation antidepressants.

Comparative benefits of pharmacologic versus nonpharmacologic treatment options for initial management: Increased response for SGA + acupuncture combination therapy vs. SGA monotherapy. SGA Versus Acupuncture. Monotherapy. Low-quality evidence from 2 trials (22, 23) showed no difference in treatment response when comparing fluoxetine with acupuncture monotherapy for patients with MDD after 6 weeks of treatment. Combination Therapy. Low-quality evidence from 2 trials (24, 25) showed that combination therapy of SGAs with acupuncture improved treatment response compared with monotherapy with SGAs (fluoxetine or paroxetine) in patients with MDD after 6 weeks of treatment. However, low-quality evidence from 1 trial (24) showed no difference in remission when comparing paroxetine monotherapy with paroxetine plus acupuncture combination therapy.
Comparative harms of pharmacologic versus nonpharmacologic treatment options for initial treatment management: Increased overall risk of adverse events with SGA vs. acupuncture. Monotherapy. Moderate-quality evidence from a systematic review of 21 trials (48) showed that the overall risk for adverse events is higher with SGAs than with acupuncture. Combination Therapy. Low-quality evidence from 1 trial showed no difference in risk for overall adverse events (49), and low-quality evidence from 2 trials showed no difference in overall discontinuation rates (24, 25) or discontinuation due to adverse events (24, 49) for SGA monotherapy versus a combination of SGA plus acupuncture.

3.10. Agency for Healthcare Research and Quality (ARQ, USA) 2015 ⊕

Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder. Agency for Healthcare Research and Quality (ARQ, USA). 2015. 274p. [192683].

For risk of harms, we graded the strength of evidence as moderate for some outcomes of three comparisons—namely, SGAs compared with CBT, acupuncture, and St. John’s wort. Patients treated with SGAs had a higher risk of experiencing adverse events or discontinuing treatment because of adverse events than patients treated with CBT, acupuncture, or St. John’s wort. Our confidence in the benefits and harms of SGAs compared with the remaining treatment options is low or insufficient, indicating that the bodies of evidence had major or unacceptable deficiencies. Nevertheless, for most comparisons, the overall findings indicated no statistically significant differences in benefits but a lower risk of adverse events for nonpharmacological treatment options. Across all comparisons of interventions, major research gaps pertain to information about the comparative risk of harms and patient-relevant outcomes such as functional capacity and quality of life.

3.11. Accident Compensation Corporation 2014 (ACC, New-Zealand) Ø

Dara S. Effectiveness of acupuncture in selected mental health conditions , Accident Compensation Corporation (ACC, New-Zealand). 2014. [182119].

There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.

3.12. Institute for Clinical Systems Improvement (ICSI, USA) 2013 ⊕

Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, Setterlund L, Somers K, Valentino N, Vincent S. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). 2013; :129P. [168070].

Acupuncture. There is considered to be high-level evidence to support the use of acupuncture during pregnancy for the treatment of depressive episodes (Sniezek, 2013). An open, parallel-arm, randomized study showed acupuncture to result in equal efficacy in comparison to counseling with a significant reduction in depressive symptoms for both in comparison to usual care (MacPherson, 2013). Existing meta-analyses and systematic reviews vary with respect to acupuncture protocol (manual, electroacupuncture or sham), methodological soundness and efficacy results (Freeman, 2010). Both sham and active acupuncture participants generally report symptomatic depression improvement (Freeman, 2010). Serious adverse events from acupuncture are very uncommon, which may appeal to those who seek to avoid side effects associated with traditional treatments (e.g., medication side effects).

Acupuncture. U.S. Navy Bureau of Medicine and Surgery. 2013.17p. [180539].

Category B (limited evidence): Authorized but not recommended for routine use (consider as adjunct). Depression

3.14. Scottish Intercollegiate Guidelines Network (SIGN, Scotland) 2010 Ø

Non-pharmaceutical management of depression in adults. Scottish Intercollegiate Guidelines Network (SIGN). 2010:44p. [196690].

Three good quality systematic reviews of poor quality RCTs of acupuncture in patients with depression were identified. Results were inconclusive and studies had a number of methodological limitations. There is insufficient evidence on which to base a recommendation.

3.15. American Psychiatric Association (APA, USA) 2010 Ø

Practice guideline for the treatment of patients with major depressive disorder. Arlington (VA): American Psychiatric Association (APA). 2010. 152P. [168023].

Based on current evidence, acupuncture is not recommended in the treatment of major depressive disorder.

Freeman MP, Fava M, Lake J, Trivedi MH, Wisner KL, Mischoulon D. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force Report. J Clin Psychiatry. 2010;71(6):669-681. [155599].

Evidence for the efficacy of acupuncture as a primary treatment of depression is inconclusive, and studies to date have failed to demonstrate efficacy of acupuncture compared to a control condition for the treatment of MDD.

3.16. Canadian Network for Mood and Anxiety Treatments (CANMAT, Canada) 2009 Ø

Ravindran AV, Lam RW, Filteau MJ, Lespérance F, Kennedy SH, Parikh SV, Patten SB; Canadian Network for Mood and Anxiety Treatments (CANMAT). Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Affect Disord. 2009;117 suppl 1:S54-64. [146622].

The current evidence does not support the use of acupuncture for the management of MDD. Insufficient evidence for recommendation

3.17. Department of Veterans Affairs (DVA, USA) 2009 Ø

Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of major depressive disorder. Washington: VA/DoD; 20109. [195515].

Action statement: Acupuncture should not be recommended as a treatment for MDD. Recommendations : There is insufficient evidence to determine the efficacy of acupuncture compared to medication, wait list control, or sham acupuncture in the management of major depressive disorder; therefore, it is not recommended as a treatment for MDD.

4. Overview of Guidelines

4.1. Fernandez-Chinguel 2020

Fernandez-Chinguel JE, Goicochea-Lugo S, Villarreal-Zegarra D, Taype-Rondan A, Zafra-Tanaka JH. Acupuncture for major depressive disorder: A review of the recommendations stated at clinical practice guidelines. Complement Ther Med. 2020. [205769]. doi

Background The use of acupuncture to treat depression is not uncommon. However, recommendations regarding acupuncture issued by clinical practice guidelines (CPG) vary widely.
ObjectiveTo describe the recommendations regarding acupuncture in CPGs for depression in adults, and to assess the methodology used to reach them.
MethodsWe conducted a scoping review of CPGs for depression management in adults, which performed systematic reviews (SRs) to answer their review questions, were published between January 2014 and May 2018, and assessed the use of acupuncture as a review question. We limited out search to articles published in English/Spanish. We assessed the SRs quality using the “A MeaSurement Tool to Assess Systematic Reviews-2” (AMSTAR-2), and described how the recommendation regarding acupuncture was reached.
Findings We found five CPGs that fulfilled our inclusion criteria: three from the US, one from Canada, and one from China. Four CPGs fulfilled between two and three items of AMSTAR-2, and one CPG fulfilled seven items. The methodology used to formulate the recommendations varied between CPGs. Regarding acupuncture use recommendations: three CPGs did not issue any recommendation (although one mentions that it should not be used), whilst two were in favor.
DiscussionsThe lack of a clearly stated review question presented in the majority of CPGs prevents the reader from understanding what the CPG developing group was trying to answer. Moreover, the arguments presented to support a decision are usually not detailed enough. Therefore, the assessment of the recommendations was extremely difficult.
Clinical implicationsGiven that the formulation of recommendations is not always reliable, clinicians should carefully read and assess the recommendations presented in CPGs before implementing them.