Are acupuncture and related therapies plus antidepressants effective for depression as compared to antidepressants alone?
Date of publication of the systematic review: May 2015
Design
Systematic review of 13 randomized controlled trials (RCTs).
Participants
1046 patients (mean age range: 33.3 to 60.6 years, male %: not reported) with depressive disorder. The DSM-III-R or DSM-IV criteria were used for diagnosis of major depressive disorder (MDD) in three of the included studies. Three studies used the International Classification of Diseases 10th Revision (ICD-10), four used the Chinese Classification of Mental Disorders III (CCMD) and the remaining studies did not report the diagnostic criteria of depressive disorder.
Intervention
Acupuncture and related therapies included manual acupuncture, electroacupuncture and acupuncture plus moxibustion. Antidepressants included selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and paroxetine, tricyclic antidepressants (TCAs) such as amitriptyline, and the tetracyclic antidepressant mianserin. The number of treatment sessions ranged from 9 to 36 and most of the therapies lasted for 6 weeks.
Comparator
Comparison: Acupuncture and related therapies plus antidepressants versus antidepressants alone.
Major Outcomes
Outcome 1: 17-item Hamilton Depression Rating Scale (HAMD-17) score at week 1;
Outcome 2: HAMD-17 score at week 6;
Outcome 3: Response rate, which was defined as the proportion of subjects who had at least some improvement in their depression level at the end of treatment.
Settings
The reviewers did not state whether the included studies were conducted in inpatient or outpatient settings
Comparison    Acupuncture and related therapies plus antidepressants versus antidepressants alone
Main Results
Compared to antidepressants alone, acupuncture and related therapies plus antidepressants significantly reduced HAMD-17 score at week 1 (pooled standardized mean difference (pooled SMD): -3.74, 95% CI: -4.77 to -2.70) and week 6 (pooled SMD: -2.52, 95% CI: -4.12 to -0.92). Response rate in the combined treatment group was significantly higher than that in the antidepressant alone group (pooled risk ratio (pooled RR): 1.23, 95% CI: 1.10 to 1.39).
Comparison: Acupuncture and related therapies plus antidepressants versus antidepressants alone for patients with depression
Outcomes No. of studies (Total no. of participants) Mean score (SD)/ No. of participants in each group Heterogeneity test (I2) Pooled SMD (95% CI) Overall quality of evidence*
Intervention Comparator
1 5 (292) Not reported/138 Not reported/154 0% -3.74 (-4.77 to -2.70) High
2 6 (339) Not reported/162 Not reported/177 71% -2.52 (-4.12 to -0.92) Moderate
Outcomes No. of studies (Total no. of participants) No. of participants who experienced the outcome/ No. of participants in each group Heterogeneity test (I2) Pooled RR (95% CI) Overall quality of evidence*
Intervention Comparator
3 13 (923) 349/460 279/463 68% 1.23 (1.10 to 1.39) High
Keys: SD: standard deviation; SMD: standardized mean difference; RR: risk ratio; CI: confidence interval.
Comparison    Acupuncture and related therapies plus antidepressants versus antidepressants alone
Main Results
Compared to antidepressants alone, acupuncture and related therapies plus antidepressants significantly reduced HAMD-17 score at week 1 (pooled standardized mean difference (pooled SMD): -3.74, 95% CI: -4.77 to -2.70) and week 6 (pooled SMD: -2.52, 95% CI: -4.12 to -0.92). Response rate in the combined treatment group was significantly higher than that in the antidepressant alone group (pooled risk ratio (pooled RR): 1.23, 95% CI: 1.10 to 1.39).
Comparison: Acupuncture and related therapies plus antidepressants versus antidepressants alone for patients with depression
Outcomes 1 2
No. of studies (Total no. of participants) 5 (292) 6 (339)
Mean score (SD)/ No. of participants in each group Intervention Not reported/138 Not reported/162
Comparator Not reported/154 Not reported/177
Pooled SMD (95% CI) -3.74 (-4.77 to -2.70) -2.52 (-4.12 to -0.92)
Overall quality of evidence* High Moderate
Outcomes 3
No. of studies (Total no. of participants) 13 (923)
No. of participants who experienced the outcome/ No. of participants in each group Intervention 349/460
Comparator 279/463
Pooled RR (95% CI) 1.23 (1.10 to 1.39)
Overall quality of evidence* High
Keys: SD: standard deviation; SMD: standardized mean difference; RR: risk ratio; CI: confidence interval.
Conclusion
Benefits
This study showed that acupuncture and related therapies plus antidepressants may significantly reduce depression at weeks 1 and 6 when compared to antidepressants alone. The response rate in the combined treatment group was significantly higher than that in the antidepressant alone group. For outcomes 1 and 3, the overall quality of evidence is high. Further research is unlikely to have an important impact on our confidence in this estimate of effect. For outcome 2, the overall quality of evidence is moderate. Further research is fairly likely to have an important impact on our confidence in this estimate of effect.
Harms
Adverse events which occurred with antidepressants mainly included nausea, dry mouth, headache and listlessness. These events were most apparent in the first 2 weeks of treatment and then relieved or disappeared as treatment progressed. Two studies reported that there were fewer adverse effects in the acupuncture and related therapies plus antidepressant group when compared to antidepressant alone group.
Link to Original Article
https://www.ncbi.nlm.nih.gov/pubmed/25704563
The synopsis is based on the following article:
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. Journal of Affective Disorders. 2015 May 1;176:106-17.


* Interpretation of quality assessment results:
• Very low: Further research is most likely to have an important impact on our confidence in this estimate of effect.
• Low: Further research is likely to have an important impact on our confidence in this estimate of effect.
• Moderate: Further research is fairly likely to have an important impact on our confidence in this estimate of effect.
• High: Further research is unlikely to have an important impact on our confidence in this estimate of effect.
• Very high: Further research is most unlikely to have an important impact on our confidence in this estimate of effect.

Details of assessment method can be found at Chung VC, Wu XY, Ziea ET, Ng BF, Wong SY, Wu JC. Assessing internal validity of clinical evidence on effectiveness of CHinese and integrative medicine: Proposed framework for a CHinese and Integrative Medicine Evidence RAting System (CHIMERAS). European Journal of Integrative Medicine. 2015 Aug 31;7(4):332-41.