ReviewThe benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis
Introduction
Depressive disorders are among the most common psychiatric disorders in adults and are associated with a substantial loss of quality of life for patients and their relatives (Saarni et al., 2007), huge social and financial burdens (Greenberg and Birnbaum, 2005, Simon et al., 2001), and result in a considerable public health disease burden (Mathers and Loncar, 2006). The 2010 Global Burden of Disease (GBD) study identified major depressive disorder as the second leading cause of disability worldwide and a major contributor to the burden of suicide and ischemic heart disease (Ferrari et al., 2013). These findings reinforce the importance of treating depressive disorders as a public health priority and of implementing cost-effective interventions to reduce its huge burden.
The symptoms of depression generally include depressed mood, fatigue, sleep difficulties, anxiety, irritability, poor concentration, poor appetite and a loss of interest in people or activities. Effective treatments are available for depression, including several types of antidepressant medication and psychotherapy (Bauer, 2007). The American Psychiatric Association 2000 Practice Guideline for the Treatment of Patients with major depressive disorder indicates that antidepressant medications may be provided as an initial primary treatment for depressive disorder. The most important classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MOIs). In regard to SSRIs, approximately 60% of patients respond well to active treatment, but approximately 30% are nonresponders (Arroll et al., 2005, Baghai et al., 2006, Ruhe et al., 2006). The effectiveness of SSRIs is consistently reduced by a lack of therapeutic effect in some depressed patients who are unable to tolerate adverse effects, and by high dropout rates. Thus, a large proportion of depressed patients cannot obtain a full remission and they experience relapse and functional impairment (Arroll et al., 2005, Blier and de Montigny, 1994). Moreover, the delayed onset of antidepressant action with SSRIs prolongs feelings of depression in patients (Blier, 2003).
This reality has led patients or researchers to search for alternative treatments that may better treat depression, particularly in the early phase of the disease (Adell et al., 2005, Pilkington et al., 2006). Acupuncture is one of the most popular complementary therapies in the West and good evidence shows that acupuncture is efficacious for various types of depressive disorders (Smith et al., 2010, Wang et al., 2008, Zhang et al., 2010). Acupuncture involves puncturing the skin with thin, sterile needles at defined acupuncture points. In manual acupuncture (MA), the needles are twisted back and forth by practitioner until DeQi is achieved, which is described as a feeling of numbness, soreness or heaviness. The effect of MA differs by the number of the needles, treatment duration and methods of manipulation. In electroacupuncture (EA), the needles are connected to an electrical stimulator delivering either high or low frequency impulses, or a combination of both. The effect of EA differs by the frequency and intensity of the electrical stimulation. Recent studies have found that EA has immediate and short-term effects in alleviating pain, autonomic dysfunction, and mood symptoms (Dhond et al., 2007, Ulett et al., 1998, Zhao, 2008). A biochemical hypothesis for the effectiveness of acupuncture in the treatment of depression is that the intervention stimulates afferent Group III nerve fibers that transmit impulses to various parts of the central nervous system and induce the release of norepinephrine, serotonin, substance P, dopamine, β-endorphin, enkephalin and dynorphins, primarily in the hypothalamus (Siedentopf et al., 2005, Ulett et al., 1998), all of which play a principal role in the pathophysiology of major depression (Belmaker and Agam, 2008).
We therefore conducted a meta-analysis using data from all relevant randomized clinical trials that had compared the effectiveness of antidepressants alone and in combination with acupuncture in the treatment of various depressive conditions. We also reviewed the quality of the study design, types of acupuncture applied, and selected acupoints or sites of the body.
Section snippets
Search strategy
In March 2014, we searched three electronic bibliographic databases (PubMed, Ebsco and the Cochrane database of randomized trials) using the search terms ‘acupuncture OR electroacupuncture’ and ‘depression OR depressive disorder OR major depression’. The search was restricted to English- and Chinese-language studies.
Inclusion criteria
We included studies that met the following criteria: (1) randomized control trials (RCTs) that adopted a double-blind, single-blind, or non-blind design and (2) patients met
Description of the studies
The search yielded 661 potential article titles for review, 616 of which were excluded for reasons of irrelevance (Fig. 1). Fifty clinical trials assessing the application of acupuncture for depression were retrieved for further assessment. Among these 50 trials, 14 were excluded due to diagnosis of post-stroke depression, postpartum depression, depression during pregnancy and depression relating to Parkinson׳s disease. Twenty-two trials did not compare antidepressants alone with acupuncture in
Discussion
This meta-analysis reveals clear evidence of greater antidepressant activity with acupuncture combined with an SSRIs compared with SSRIs alone over the initial six weeks of treatment. In six trials, the combination of acupuncture and SSRI resulted in a greater mean reduction in HAMD-17 scores in the first week of treatment than that seen with SSRIs alone, which indicates that the addition of acupuncture may cause an earlier onset of action with SSRIs. Research has not yet been able to clarify
Conclusion
In conclusion, this meta-analysis of data from 13 RCTs indicates that combined acupuncture and antidepressant treatment is more effective than antidepressants alone in the first 6 weeks of treatment. Acupuncture has the potential to be an effective, safe and well-tolerated therapy with early onset in depression and may help to reduce side effects of antidepressants. There are no reports regarding the use of acupuncture for preventing recurrence after recovery from a depressive episode. Further
Role of funding source
The funding sources for the study (China Medical University and the Ministry of Science and Technology, Taiwan) had no role in study design, data analysis, writing of the manuscript or decision to submit the paper for publication.
Conflict of interest
The authors have no competing conflicts of interest.
Acknowledgments
We would like to thank Ms. Iona MacDonald for her input into the preparation of this manuscript. This work was supported by grant of A-4-1-a from China Medical University under the Aim for Top University Plan of the Ministry of Education, Taiwan and by grants of MOST103-2320-B-039-008- and 102-2320-B-039-029- from the Ministry of Science and Technology, Taipei, Taiwan.
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