Is manual acupuncture effective for treating depression in adults as compared to conventional anti-depression drugs?
Date of Publication of the systematic review: January 2010
Design
Systematic review of 4 randomized controlled trials (RCTs).
Participants
216 adults diagnosed with depression by the Diagnostic and Statistical Manual of Mental Disorders (DSM), or the Chinese Classification of Mental Disorders (CCMD-2 or CCMD-3). The reviewers did not state the exact range of age and gender proportion. Patients who had no history of depression but diagnosed with depression as co-morbidity after stroke were not included in this summary.
Intervention
Manual acupuncture with varying pattern of point selection were delivered at the frequency of 30 minutes a session, one session a day for at least five days a week during 6 to 12 weeks. Acupuncture points included located on the arms, legs, abdomen and head. Two trials used a standardized treatment protocol with a fixed selection of points administered at each acupuncture session. One trial used a semi-standardized treatment protocol consisting of a pre-defined set of acupuncture points used in combination with acupuncture points selected on the basis of the identification of a symptomatic pattern. One trial used individualized treatment protocol for study participants based on their TCM syndrome differentiation.
Comparator
Comparison 1: Manual acupuncture versus amitriptyline;
Comparison 2: Manual acupuncture versus fluoxetine hydrochloride.
Amitriptyline was administered orally at a dose of 25 mg on the first day. The dose was increased by 25-50 mg each day up to 150 mg. In the second week the dose was adjusted according to response and side effects but ranged from150 mg to 300 mg daily.
Fluoxetine hydrochloride (trade name: Prozac), a selective serotonin reuptake inhibitor (SSRI), was administered orally at a dose of 20 mg a day for 6 to 12 weeks.
Major Outcomes
Outcome 1: Reduction in the severity of depression measured as difference before and after treatment using the Hamilton Rating Scale at the end of treatment (6 to 12 weeks). Score range of the scale was not described and only standardized effect was provided by the reviewers.
Settings
All 4 included trials were undertaken in China. One trial recruited patients from an inpatient hospital setting; two trials recruited patients from both in and outpatient settings; one trial did not state whether patients were recruited from in or outpatient settings.
Comparison    Manual acupuncture versus amitriptyline
Main Results
Compared to amitriptyline, manual acupuncture did not show significant improvement on the reduction of the severity of depression at the end of treatment (6 weeks) (standardized mean difference (SMD): 0.33, 95% CI: -0.29 to 0.94).
Comparison 1: Manual acupuncture versus amitriptyline in patients with depression
Outcomes (units) No. of studies (Total number of participants) Mean/No. of participants Heterogeneity test (I2) SMD (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 1 (41) 15.5/20 12.8/21 Not applicable as there is only 1 study. 0.33 (-0.29 to 0.94) Low
Keys: SMD = standardized mean difference; CI = confidence interval.
Comparison    Manual acupuncture versus fluoxetine hydrochloride
Main Results
Compared to fluoxetine hydrochloride, manual acupuncture has similar curative effect on the reduction of the severity of depression at the end of treatment (6 to 12 weeks) (pooled SMD:-0.02, 95% CI: -0.33 to -0.28).
Comparison 2: Manual acupuncture versus fluoxetine hydrochloride in patients with depression
Outcomes (units) No. of studies (Total number of participants) Mean/No. of participants Heterogeneity test (I2) Pooled SMD (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 3 (175) Not reported/95 Not reported/80 0% -0.02 (-0.33 to 0.28) Moderate
Keys: SMD = standardized mean difference; CI = confidence interval.
Comparison    Manual acupuncture versus amitriptyline
Main Results
Compared to amitriptyline, manual acupuncture did not show significant improvement on the reduction of the severity of depression at the end of treatment (6 weeks) (standardized mean difference (SMD): 0.33, 95% CI: -0.29 to 0.94).
Comparison 1: Manual acupuncture versus amitriptyline in patients with depression
Outcomes (units) 1 (NA)
No. of studies (Total number of participants) 1 (41)
Mean/No. of participants Intervention 15.5/20
Comparator 12.8/21
SMD (95% CI) 0.33 (-0.29 to 0.94)
Overall quality of evidence* Low
Keys: SMD = standardized mean difference; CI = confidence interval.
Comparison    Manual acupuncture versus fluoxetine hydrochloride
Main Results
Compared to fluoxetine hydrochloride, manual acupuncture has similar curative effect on the reduction of the severity of depression at the end of treatment (6 to 12 weeks) (pooled SMD:-0.02, 95% CI: -0.33 to -0.28).
Comparison 2: Manual acupuncture versus fluoxetine hydrochloride in patients with depression
Outcomes (units) 1 (NA)
No. of studies (Total number of participants) 3 (175)
Mean/No. of participants Intervention Not reported/95
Comparator Not reported/80
Pooled SMD (95% CI) -0.02 (-0.33 to 0.28)
Overall quality of evidence* Moderate
Keys: SMD = standardized mean difference; CI = confidence interval.
Conclusion
Benefits
Compared to amitriptyline, manual acupuncture did not show significant benefits for patients with depression on the important outcome: reduction of the severity of depression at the end of treatment (6 weeks). The overall quality of evidence is low. Further research is likely to have an important impact on our confidence in this estimate of effect. Compared to fluoxetine hydrochloride, manual acupuncture has similar curative effect for patients with depression on the important outcome: reduction of the severity of depression at the end of treatment (6 to 12 weeks). 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
None of the 4 included trials reported any information on adverse events.
Link to Original Article
http://www.ncbi.nlm.nih.gov/pubmed/20091556
The synopsis is based on the following article:
Smith CA, Hay PPJ, MacPherson H. Acupuncture for depression. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004046. DOI: 10.1002/14651858.CD004046.pub3.


* 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.