Inspired by Yin et al 2022.[1]
EA – electroacupuncture
key to acronyms
MA – manual acupuncture
SC – standard care
PSQI – Pittsburgh Sleep Quality Index
HAM-D – Hamilton Depression Rating Scale
HAMD-17 – the sum of the first 17 items on the HAM-D
This 3-armed trial from Shanghai is the biggest trial (n=270) of acupuncture (MA plus EA) for depression-related insomnia to date.
It compared real acupuncture plus SC with a non-penetrating sham (Streitberger sham device) plus SC against SC alone. EA was applied between GV20 and Yintang (also referred to as GV29 in this paper), which is a very common approach used in studies on depression. MA was applied at GV24, Anmian (an extra point on the mastoid process), HT7, PC6, and SP6. Treatments were given 3 times a week for 8 weeks and follow-up continued for a further 6 months ie 8 months from the start of the trial.
EA between GV20 and Yintang
3x per week for 8 weeks
The primary outcome was the PSQI, which I have discussed on a previous blog: EA for sleep. In brief, it scores from 0 to 21, with higher scores indicating worse sleep quality, and a score of 5 or more being compatible with sleep problems.
All 3 groups started with a similar PSQI of ~15 and this score fell over the course of the 8-week treatment period in all groups; however, by 4 weeks (12 sessions) the EA group was significantly better than the sham group, which was significantly better than the SC group. By 8 weeks the EA group PSQI was below 10 and it stayed below 10 for the follow-up period. The other 2 groups scored just over 14 by week 32 (6 months follow-up).
PSQI – 0 to 21 scale
≥5 = sleep problem
So, this is a pretty good result, although the mean sleep quality in the EA group did not reach a normal level. Amongst the secondary outcome measures was the HAMD-17 (referred to in the paper as HDRS-17). The mean baseline score on this scale was 24 meaning that the majority of patients were severely depressed. After the treatment phase this mean score dropped by 10 to 11 points in the EA group, which is still in the range of moderate depression. Interestingly, the score in the sham group dropped by 5 points at week 8, which was significantly more than the SC control, but by week 32 it was no different and less than 2 points below the baseline value ie back in the severe depression range.
The same first author (and last author, ie same team) published a smaller 3-arm efficacy trial (n=90) in 2020.[2] The same population was used, although they were marginally worse on both PSQI (>16) and HAMD-17 (27 to 28). In this trial they used the same point protocol described above, and I am pleased to see that they included details of the EA parameters in this report (30Hz, 175μs square wave, 0.1 to 1mA). They also used the same frequency (3x per week) and total duration of treatment (8 weeks).
Two different control groups were used: superficial needling at sham points; and non-penetrating sham acupuncture at the same points. The EA group performed rather similarly to that in the larger, more recent trial, but there was an interesting difference in the outcomes between the superficial and non-penetrating controls. There was little difference between them on the PSQI, with both groups dropping 2 to 3 points by the end of the treatment phase. However, on the HAMD-17, the drop in mean score was more than twice as large in the superficial needling (>5) group compared with the non-penetrating sham group (~2). In the EA group the HAMD-17 dropped from 28 at baseline to 11 at the end of treatment – more than 3x as much as in the superficial needling control.
The larger and more recent paper in JAMA Network Open was accompanied by an editorial written by a couple of academics from Harvard who research on depression.[3] I had not come across their names, but they helpfully self-cited a couple of small cohort studies (both n=30) of acupuncture in depression. The first one recruited patients who were partial or non-responders to antidepressant medication.[4] The second used acupuncture as a monotherapy – I guess that was quite brave in the West.[5] In both cohorts, the patients were given a choice of once-weekly or twice-weekly treatment sessions with a standard protocol of MA (HT7, LI4, ST36, SP6, LR3) plus EA (GV20 to Yintang – in this paper Yintang was referred to as GV24.5). There was no difference between these two regimes, and only a small number of patients opted for twice-weekly treatment – 2 in the 2011 study and 6 in the 2012 study.
Almost every trial I have ever seen of acupuncture in depression has used EA from GV20 to Yintang. I think we should try and break out of this mould, and for the last 20 plus years I have been using ST36 to Zongping of course, as I prefer to mimic strong exercise rather than needle the scalp.[6]
I should mention the large pragmatic trial (n=755) of acupuncture and counselling versus usual care alone in the UK led by Hugh McPherson.[7] In this trial EA was only used 7% of the time, and the most commonly used points were ST36, SP6, LR3, and LI4.
References
1 Yin X, Li W, Liang T, et al. Effect of Electroacupuncture on Insomnia in Patients With Depression: A Randomized Clinical Trial. JAMA Netw Open 2022;5:e2220563. doi:10.1001/jamanetworkopen.2022.20563
2 Yin X, Li W, Wu H, et al. Efficacy of Electroacupuncture on Treating Depression-Related Insomnia: A Randomized Controlled Trial. Nat Sci Sleep 2020;12:497–508. doi:10.2147/NSS.S253320
3 Yeung A, Mischoulon D. Effects of Electroacupuncture for Depression-Related Insomnia. JAMA Netw Open 2022;5:e2220573. doi:10.1001/jamanetworkopen.2022.20573
4 Yeung AS, Ameral VE, Chuzi SE, et al. A pilot study of acupuncture augmentation therapy in antidepressant partial and non-responders with major depressive disorder. J Affect Disord 2011;130:285–9. doi:10.1016/j.jad.2010.07.025
5 Mischoulon D, Brill CD, Ameral VE, et al. A pilot study of acupuncture monotherapy in patients with major depressive disorder. J Affect Disord 2012;141:469–73. doi:10.1016/j.jad.2012.03.023
6 Andersson S, Lundeberg T. Acupuncture–from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses 1995;45:271–81.
7 MacPherson H, Richmond S, Bland M, et al. Acupuncture and counselling for depression in primary care: a randomised controlled trial. PLoS Med 2013;10:e1001518. doi:10.1371/journal.pmed.1001518
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