Stimulated by Hu et al 2021.
MDD – major depressive disorderkey to acronyms
NMA – network meta-analysis
EA – electroacupuncture
MA – manual acupuncture
HAMD-17 – Hamilton depression rating scale (17 item)
SSRIs – selective serotonin reuptake inhibitors
SNRIs – serotonin noradrenaline reuptake inhibitors
NASSAs – noradrenaline and specific serotoninergic antidepressants
TCAs – tricyclic antidepressants
This is the first network meta-analysis (NMA) examining the effectiveness of acupuncture in depression. It is published in the journal Scientific Reports, which has an impact factor of over 4, and is published by the Nature Publishing Group.
The team who conducted this review are from Hong Kong, Lanzhou, McMaster and Guangzhou.
71 studies (RCTs) were included with a total of 5856 patients. As I ran my eye down the table of characteristics of the included studies, I could see that most trials included less than 100 patients, as the figures above would imply (5856/72 is about 82). One relatively recent trial stood out – a three armed trial with 477 patients. This was a multicentre trial based in China and patients were randomised to receive either EA or MA in addition to an SSRI, or an SSRI alone. The EA or MA was applied 3 times per week for 6 weeks. A standard protocol was used, which included brief needling of GV14 and GV16 in sequence for 30 seconds, followed by GV20, Yintang, GB20 PC6 and SP6 for 30 minutes. In the EA group, EA was applied to GV20–Yintang and GB20–GB20, and 2/15Hz was used.
All groups improved over the 6 weeks treatment and at 10 weeks follow up, but the acupuncture groups improved more quickly and to a slightly greater degree. Both EA and MA were significantly better than SSRIs alone in the primary outcome, and the figures for EA were always a little better than MA but this was not significant.
I was particularly interested to see that side-effects were considerably reduced in the groups that received either EA or MA.
Adding EA to SSRIs in MDD would result in about 29 (15 – 49) more patients benefiting in every 100. The figure for MA is 21 (9 – 39).
Going back to the NMA, we see that the majority of the data concerns similar comparisons to those in this large 3-armed trial, but there are also quite thick lines in the network plot between EA or MA alone and SSRIs.
The main network included 50 studies and 3881 patients where HAMD-17 data was available. In this network, EA plus SSRIs came out on top followed closely by MA plus SSRIs. Next was MA alone, NASSAs, EA alone and finally SSRIs before the groups including sham techniques.
SNRIs did not figure in the data because the few trials in which these drugs were used formed a network that did not connect to the larger network. In this small network MA plus SNRIs proved to be top, followed by EA plus SNRIs and SNRIs alone.
So, it looks as though there is good evidence for adding EA or MA to standard drug treatment of depression with the bonus for the patients of reduced side-effects, presumably related to the drugs themselves.
1 Hu Z, Lam WC, Li H, et al. A network meta-analysis on the effectiveness and safety of acupuncture in treating patients with major depressive disorder. Sci Rep 2021;11:10384. doi:10.1038/s41598-021-88263-y
2 Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62. doi:10.1136/jnnp.23.1.56
3 Zhao B, Li Z, Wang Y, et al. Manual or electroacupuncture as an add-on therapy to SSRIs for depression: A randomized controlled trial. J Psychiatr Res 2019;114:24–33. doi:10.1016/j.jpsychires.2019.04.005