Acupuncture treatment for depression—A systematic review and meta-analysis

Efficacy and safety of acupuncture for depression: A systematic review and meta-analysis

Acupuncture is widely accepted as a therapeutic option for managing depression. However, evidence from clinical trials remains controversial. This review aims to synthesize the best available evidence on the efficacy and safety of acupuncture in managing depression. The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Five databases and the relevant trial registries were searched from the inception to October 2021. Randomized clinical trials of acupuncture for managing depression, published in English, were selected for inclusion. The quality of included studies was assessed using the Cochrane risk of bias tool. Netmeta and dmetar of R packages were used to conduct a network meta-analysis. Twenty-two trials with 2391 participants were eligible and included in the analysis. This review found evidence that electroacupuncture (EA) plus antidepressant achieved superior outcomes compared with the waitlist (standardized mean difference = -8.86, 95% confidence interval: -14.78 to -2.93). The treatment ranking of different interventions in improving depression symptoms indicated that EA plus antidepressant with a probability of 0.8294, followed by manual acupuncture (MA) plus antidepressant (0.6470) and MA (0.5232). Acupuncture, either in isolation or as an adjunct to pharmacological treatment, has clinical benefits and can be considered a safe option for managing depression.

Understanding Traditional Chinese Medicine Therapeutics: An Overview of the Basics and Clinical Applications

Traditional Chinese medicine (TCM) is a systematic healthcare system developed from clinical experience based on a scientific model of regulation. TCM relies on unique theories and practices to treat diseases and enhance health. These practices include Chinese herbal medicine and dietetics, acupuncture and moxibustion, and other non-medication therapies such as Chinese bodywork or manual therapy, known as "Tuina", and traditional biofeedback exercises, known as "Qigong" and "Taijiquan". The integration of TCM in Western health systems and research requires a rational communicable theory, scientific proof of efficacy and safety, and quality control measures. Understanding the structural concepts of the TCM language makes possible the parallelism to Western physiology, and the inherent rational use of the reflex therapeutic systems, anti-inflammatory mechanisms and mental training involved, for example, in acupuncture and "Qigong". The results of TCM clinical trials and fundamental research on its nature and mechanisms have encouraged the development and application of well-designed research strategies such as double blinding in acupucture to overcome limitations and resistances in integrating these practices into the existing biomedical paradigms of the West. This review aims to overview some TCM theoretical concepts and the evidence-based clinical application of TCM's leading practices to create an easy-to-consult and condensed source of information, available for the healthcare community, facilitating the understanding and communication between conventional health professionals and TCM practitioners and acupuncturists.

The feasibility of acupuncture as an adjunct intervention for antenatal depression: a pragmatic randomised controlled trial

BACKGROUND

Antenatal depression is common and associated with adverse consequences for mothers, babies, and future generations. Limitations with conventional approaches has resulted in additional therapies being considered. This study examined the feasibility and effectiveness of acupuncture for improving mental health.

METHODS

Fifty-seven pregnant women with depressive symptomologies were randomised to acupuncture (n=19) plus treatment as usual (TAU), progressive muscle relaxation (PMR, n=19) plus TAU or TAU (n=19). Treatments were conducted from 24 to 31 weeks gestation. Clinical assessments were performed throughout the intervention, as well as at a six-week postnatal follow-up. The primary outcome measure was depression. Secondary outcome measurements were stress, anxiety, psychological distress, quality of life and adjustment to mothering. Intention to treat (ITT), Linear Mixed Model (LMM) repeated measures and per protocol (PP) analyses were conducted.

RESULTS

At end-of-intervention there were significantly lower depression scores in the acupuncture group versus TAU and PMR respectively [ITT p<0.001, mean difference (MD) -5.84 (95% CI -9.10 to -2.58); MD -3.42 (95% CI -6.64 to -0.20)]. LMM repeated measures analysis (including postnatal follow-up) also demonstrated significantly lowered acupuncture group scores for stress (p=0.006) and psychological distress (p<0.001) when compared to PMR and TAU. Between group differences were not significant at six-weeks postnatal. No adverse events were reported.

LIMITATIONS

Main limitations are small sample size and the use of self-reported outcome measures.

CONCLUSION

Prenatal acupuncture reduced depression, stress and distress, whilst also being well-tolerated and free from adverse events. Further research is warranted.

Risk of bias assessments and reporting quality of systematic reviews and randomized controlled trials examining acupuncture for depression: An overview and meta-epidemiology study

OBJECTIVES

To assess the use of risk of bias (ROB) assessment tools and the reporting quality of ROB assessment results in systematic reviews (SRs) of acupuncture for depression, as well as to evaluate the ROB of depression-related randomized controlled trials (RCT).

METHODS

Embase, Medline, Chinese Journal Full-Text Database (CJFD), VIP Chinese Technology Periodical Database, and WanFang Data Resource System of Digital Periodicals were searched from their inception to 24 November 2017. SRs of RCTs concerning acupuncture on depression were included. General characteristics and the information related to risk of bias in SRs were extracted. A descriptive analysis was used.

RESULTS

Thirty-nine SRs were included. Of these, two (5%) did not perform a ROB assessment, 18.9% did not report the ROB assessment results, and 62.2% did not report the assessment results of each ROB item. Text descriptions and tables were commonly used in reporting forms. Only 32.4% of SRs reported support for judgment. The reporting rate of ROB assessment results was low in all items (13.5%-35.1%). Regarding RCTs, 59.7% used adequate randomization methods, 13.1% performed adequate allocation concealment, 12.5% performed adequate blinding of participants and personnel, 27.3% performed adequate blinding of the assessment outcomes, and 41.5% and 49.3% had a low ROB in terms of incomplete outcome data and selective outcome reporting, respectively.

CONCLUSION

For the SRs of acupuncture for depression, the selection of ROB assessment tools needs to be optimized. The reporting quality is poor, and the overall ROB of RCTs is high. Therefore, the results may not be reliable.

The effectiveness and safety of acupuncture for depression: An overview of meta-analyses

PURPOSE

To provide an overview of existing meta-analysis (MAs) on the efficacy and safety of acupuncture for depression, and assess the methodological quality and the strength of evidence of the included MAs.

METHODS

We searched MAs of randomized trials that have evaluated the effects of acupuncture on depression in three international and three Chinese databases from their inception until August 2019. The methodological quality of included MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the strength of evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We used the intra-class correlation coefficient (ICC) to assess reviewer agreement in the pre-experiment.

RESULTS

We included 31 MAs and 59 RCTs. The results of included MAs were conflicting, our meta-analyses found that acupuncture may confer small benefit in reducing the severity of depression by end of treatment than no treatment/wait list/treatment as usual(SMD -0.74, 95% CI -1.06 to -0.41, eight trials, 624 participants), control acupuncture (invasive, non-invasive sham controls) (SMD 0.27, 95% CI -0.51 to -0.04, 20 trials, 1055 participants), antidepressants(Selective serotonin reuptake inhibitors (SSRI)/ Tetracyclic antidepressants(TCAs)) (SMD -0.28, 95% CI -0.46 to -0.10, 30 trials, 3068 participants), acupuncture plus antidepressants versus antidepressants(SSRI/TCAs) (SMD -0.99, 95% CI -1.37 to -0.61, 17 trials, 1110 participants). Subgroup analyses showed that there was no difference between electro-acupuncture and invasive control (P = 0.37), electro-acupuncture and non-invasive control (P = 0.90), manual acupuncture and Tetracyclic antidepressants (P = 0.57), electro-acupuncture and Tetracyclic antidepressants (P = 0.07). Six MAs concluded that acupuncture reduced the incidence of adverse events compared with antidepressants. The evaluation with AMSTAR-2 showed that the quality of included MAs was low or critically low. The results of the GRADE evaluation showed that the strength of evidence was low to very low for most outcomes.

CONCLUSIONS

Although acupuncture appears to be more effective and safer than no treatment, control acupuncture and antidepressants, the quality of the available evidence was very low. Further methodologically rigorous and adequately powered primary studies are needed to confirm the effectiveness of acupuncture for depression.

GV 20's Role in In Vitro Fertilization and Frozen Embryo Transfer

Background: Unexplained infertility is failure to conceive after 1 year in couples with normal semen samples and no abnormalities. Acupuncture to certain points along a meridian can affect the hypothalamic-pituitary-axis (HPA) by affecting the sensory nerve fibers, blood vasculature, and autonomic nervous system. GV 20, a point at the vertex of the head, is commonly utilized in acupuncture for infertility. Engagement of the HPA axis via GV 20 stimulation should always be considered when treating a woman, with a history of ovarian dysfunction and subsequent infertility, undergoing in vitro fertilization (IVF). This point, due to its systemic effects, should be considered prior to undergoing frozen embryo transfer (FET). Case: A patient was diagnosed with unexplained infertility when she underwent IVF and FET procedures. GV 20 stimulation helped this patient by improving her mood and ameliorating her psychiatric symptoms via suspected engagement of the HPA axis. Results: As of this writing, the patient has had a relatively uneventful, successful pregnancy and is currently at 28 weeks' gestation. The couple are happily expecting a baby boy. Conclusions: Practitioners should use GV 20 to address psychologic concerns, especially in patients seeking assistive reproductive technologies. The general sense of well-being induced by GV 20 stimulation involves engaging the HPA axis. More research on GV 20's effect on regulation of hormonal imbalances, mood, anxiety, and depression via the HPA axis is warranted as is research on how GV 20 stimulation affects prolactin levels when treating hyperprolactinemia, and subsequently, dopamine utilization.

Factor analysis of electroacupuncture and selective serotonin reuptake inhibitors for major depressive disorder: an 8-week controlled clinical trial

BACKGROUND

There is evidence supporting electroacupuncture (EA) for the treatment of major depressive disorder (MDD), but its characteristics have not been well investigated.

OBJECTIVE

To investigate the effectiveness and characteristics of EA in MDD.

METHODS

60 subjects were enrolled-35 in the EA group and 25 in the selective serotonin reuptake inhibitor (SSRI) group based on their preferences-in an 8-week non-randomised controlled clinical trial. The 24-item Hamilton depression rating scale (HAMD-24) and clinical global impression (CGI) were adopted for clinical assessment. The Columbia suicide severity rating scale and adverse event form were used to measure safety and tolerability. The characteristics of EA and SSRIs were compared by analysing seven factors of the HAMD-24.

RESULTS

There was no significant difference between the two groups in terms of HAMD-24 response rate after intervention (P>0.05). Patients treated with EA demonstrated a significant reduction in CGI scores (P<0.05) with fewer adverse events compared with SSRIs (P<0.01). Although HAMD-24 factor analysis showed both EA and SSRIs could improve factor scores in cognitive impairment, diurnal variation, retardation, sleep disturbance, anxiety/somatisation and feelings of despair, EA showed greater improvement in anxiety/somatisation and feelings of despair than SSRIs (P<0.05).

CONCLUSIONS

There was no significant difference between EA and SSRIs in the treatment of MDD with respect to our primary outcome. However, as a potential therapy for MDD, EA appeared to result in greater symptom improvement than SSRI treatment with respect to anxiety/somatisation and feelings of despair. The results of this secondary analysis should be interpreted cautiously given the inherent issues of multiple testing.

Effectiveness of acupuncture in postpartum depression: a systematic review and meta-analysis

OBJECTIVE

To assess the clinical effectiveness of acupuncture in the treatment of postpartum depression (PPD).

METHODS

The following electronic databases were systematically searched: PubMed, Cochrane Library, SCI, Elsevier SDOL, China National Knowledge, Wan Fang database and Chinese Science and Technology Periodical Database. Only randomised controlled trials (RCTs) of acupuncture for PPD were considered. Primary outcomes were the Hamilton Rating Scale for Depression (HAMD) or the Edinburgh Postnatal Depression Scale (EPDS) scores and effective rate. Our secondary outcome was the level of oestradiol. The quality of all included trials was evaluated according to the Cochrane Collaboration. This protocol was registered in PROSPERO (CRD42016048528).

RESULTS

Nine trials involving 653 women were selected. The result of this meta-analysis demonstrated that the acupuncture group had a significantly greater overall effective rate compared with the control group (seven trials, n=576, I²=24%; relative risk (RR) 1.15, 95% CI 1.06 to 1.24; P<0.001). Moreover, acupuncture significantly increased oestradiol levels compared with the control group (mean difference (MD) 36.92, 95% CI 23.14 to 50.71, P<0.001). Regarding the HAMD and EPDS scores, no difference was found between the two groups (five trials, n=276, I²=82%; MD-1.38, 95% CI -3.40 to 0.64; P=0.18; two trials, n=60, I2=16%; MD 1.08, 95% CI -1.09 to 3.26; P=0.33).

CONCLUSIONS

Acupuncture appears to be effective for postpartum depression with respect to certain outcomes. However, the evidence thus far is inconclusive. Further high-quality RCTs following standardised guidelines with a low risk of bias are needed to confirm the effectiveness of acupuncture for postpartum depression.

Antidepressant effects of acupoint stimulation and fluoxetine by increasing dendritic arborization and spine density in CA1 hippocampal neurons of socially isolated rats

Given the importance of depression and the adverse effects of conventional treatment, it is necessary to seek complementary therapies. In a rat model of depression, this study aimed to assess the behavioral and morphological effects of embedding absorbable thread in acupoints (acu-catgut), and compare the results to those of fluoxetine treatment and the corresponding control groups. Therefore, depressive-like behavior was evaluated with the forced swimming test, and dendritic morphology (in the CA1 hippocampal region) with the Golgi-Cox technique and Sholl analysis. After weaning, male Sprague-Dawley rats were housed in social isolation for 8 weeks to induce depressive-like behavior. They were then given a 21-day treatment by stimulating acupoints with acu-catgut (AC) or fluoxetine (FX) (2 mg/kg). Rats were divided into six groups: Control (socially housed), social isolation (SI), SI + AC, SI + Sham (sham embedding of thread), SI + FX and SI + VH (vehicle). Compared to fluoxetine, acu-catgut treatment was more effective in reversing depressive-like behavior elicited by SI. The SI-induced reduction in dendritic length and spine density in hippocampal CA1 pyramidal neurons was attenuated after prolonged treatment with acu-catgut or fluoxetine. Hence, both treatments proved capable of reversing depressive-like alterations caused by SI, likely due to dendritic remodeling in the hippocampus.

Development of a valid and reliable seven emotions impairment questionnaire and assessment of its predictability for phlegm and blood stasis

OBJECTIVE

To develop and validate a Seven Emotions Impairment questionnaire (SEIQ), to define an optimum cut-off point for the SEIQ, and to examine whether SEI was predictive of Phlegm and Blood Stasis (BS).

METHODS

Two hundred outpatients and 75 college students were asked to complete the SEIQ, the Profile of Mood States (POMS), Phlegm Pattern Questionnaire (PPQ), and BS Questionnaire (BSQ). Twelve clinicians determined whether the outpatients exhibited SEI. SEIQ data were used to examine the internal consistency and determine validity for the outpatients. SEIQ, POMS, PPQ, and BSQ data were used to examine concurrent validity and predictability of SEI for Phlegm and BS in the college students. Total SEIQ scores and the clinicians' diagnoses of the outpatients were considered to define an optimum cut-off score for the SEIQ.

RESULTS

The 18-item SEIQ had satisfactory internal consistency (α = 0.905) and concurrent validity. In the construct validity test, four factors (chest-anxiety, fatigue-depression, working-family-troubles, and sleep-memory) were identified. In the receiver operator characteristic curve curve analysis, the sensitivity, specificity, and area under the curve of the SEIQ were 67.2%, 72.1%, and 73%, respectively. The optimum cut-off score was defined as nine points. SEIQ scores were strongly predictive of Phlegm and BS (β = 0.862 and 0.673, respectively).

CONCLUSION

Based on our results, we concluded that the SEIQ is a reliable and valid instrument for evaluating SEI, and is strongly predictive of Phlegm and BS.

Effect of Manual Acupuncture Stimulation at "Bai-Hui" (GV 20) or "Yintáng" (Ex-HN3) on Depressed Rats

A previous study on rats showed that simultaneous acupuncture stimulation at the "Bai-Hui" (GV 20) and the "Yintáng" (Ex-HN3) acupoints alleviated the state of depression to an extent similar to that achieved by pharmacotherapy. This study investigated whether the alleviation of the depressed state required simultaneous acupuncture at these two acupuncture points. For the purposes of testing the effect of acupuncture on depressive symptoms, we treated a depression model rat, where depression had been induced by using a mild water-immersion stress technique, with either acupuncture stimulation at only one acupuncture point (GV 20 or Ex-HN3) or an antidepressant, and we measured the immobile time for evaluating the state of depression. Anxiety, as a symptom commonly associated with depression, was also evaluated by measuring the number of head dips. Neither the immobile time nor the number of head dips decreased upon acupuncture stimulation. From this study, single acupuncture stimulation at either "GV 20" or "Ex-HN3" alleviated neither the state of depression nor the anxiety. The water-immersion stress used to make the depression model rats was shown not to induce anxiety; however, the stress induced by immobilizing the rats for acupuncture stimulation did lead to anxiety.

Evaluation of an antenatal acupuncture intervention as an adjunct therapy for antenatal depression (AcuAnteDep): study protocol for a pragmatic randomised controlled trial

BACKGROUND

Depressed pregnant women face difficulty navigating a course between the potentially serious consequences of leaving depression untreated and significant limitations associated with conventional therapies, such as foetal toxicity and teratogenicity. Preliminary evidence is suggestive that acupuncture may provide a safe and effective alternative treatment option for antenatal depression; however, additional research is required. The purpose of this study is to further investigate this treatment possibility, with an additional examination of a potential biomechanistic acupuncture effect.

METHODS/DESIGN

In this pragmatic randomised controlled trial, we will compare individually tailored, flexible antenatal depression-oriented acupuncture with equivalent attention progressive muscle relaxation and routine antenatal depression hospital care. Eligible women at 24 weeks of gestation with Edinburgh Postnatal Depression Scale scores of 13 or more will be recruited from 2 antenatal clinics in South Western Sydney, Australia. The recruitment goal of 96 is powered to demonstrate a significant difference in Edinburgh Postnatal Depression Scale score severity between acupuncture and usual care, with intervention groups receiving weekly 1-h treatments for 8 weeks from 24 to 31 weeks of gestation. Mental health and quality-of-life assessments will occur at study commencement, intervention weeks 4 and 8 and 6 weeks post-natally via the collection of completed Edinburgh Postnatal Depression Scale scores, Depression, Stress and Anxiety Scale scores and World Health Organisation Quality of Life Scale scores. Adjustment to mothering will also be evaluated at 6 weeks post-natally using the Being a Mother Scale. A putative biomechanistic effect of acupuncture on the oxytocinergic system will additionally be examined by comparing baseline salivary hormone levels with those measured at intervention weeks 4 and 8, as well as leucocyte oxytocin receptor expression at baseline and intervention week 8.

DISCUSSION

Ethical approval was received in February 2015, and recruitment is underway and expected to be completed in July 2016.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000250538, Registered on 19 March 2015.

Quality of life, sense of coherence and experiences with three different treatments in patients with psychological distress in primary care: a mixed-methods study

Background

Psychological distress is associated with impaired health-related quality of life (HRQL) and poor sense of coherence (SOC). In a previous study, we found that therapeutic acupuncture (TA) and an integrative treatment that combined TA with person-centred approach in a salutogenic dialogue (IT) alleviated anxiety and depression significantly more than conventional treatment (CT) in primary care patients. Here, we report on secondary analyses regarding the HRQL and SOC from that previous pragmatic randomised controlled trial (RCT).

Method

Quantitative and qualitative design. One hundred twenty patients were referred for psychological distress. Quantitative analyses were performed at baseline and after 8 weeks of treatment using the SF-36 mental component summary (MCS), physical component summary (PCS) and the Sense of Coherence-13 (SOC) questionnaires. Qualitative manifest content analyses were based on open-ended questions—“Have you experienced any changes since the start of the treatment? Will you describe these changes?”

Results

No baseline differences were found. At 8 weeks, both the IT and TA groups had statistically better scores and greater improvement from baseline on the MCS and SOC than the CT group. The effect sizes were large. No significant differences were found between the IT and TA groups or in relation to the PCS. SOC was highly correlated with the MCS but not with the PCS. Dropout rates were low.

The experiences of the intervention resulted in four categories: Being heading back; Status quo; Feeling confirmed; and Feeling abandoned, with 13 related subcategories.

Conclusion

IT and TA seem to improve sense of coherence and mental health status in primary care patients with psychological distress, whereas CT appears to be less beneficial. IT and TA appear to be well-accepted and may serve as useful adjunct treatment modalities to standard primary care. Our results are consistent with much of the previous research in highlighting a strong relationship between SOC and mental health status. The written qualitative data described feeling confirmed and feeling increased self-efficacy, self-care and faith in the future. Those in the CT group, however, described feeling abandoned, missing treatment and experiencing increased emotional and physical problems. More research is needed.

Trial registration

ISRCTN trial number NCT01631500.

Six-month effects of integrative treatment, therapeutic acupuncture and conventional treatment in alleviating psychological distress in primary care patients--follow up from an open, pragmatic randomized controlled trial

BACKGROUND

To evaluate and compare 6-month effects of 8 weeks of an integrative treatment (IT), therapeutic acupuncture (TA), and conventional treatment (CT) in reducing symptoms of anxiety, depression and in improving health-related quality of life (HRQL) and sense of coherence (SOC) in psychologically distressed primary care patients.

METHODS

Patients who had participated in an open, pragmatic randomized controlled trial were followed up six months after treatment. The study sample consisted of 120 adults (40 per treatment arm) aged 20 to 55 years referred from four different primary health care centres in western Sweden for psychological distress. Assessments were made at baseline after eight weeks and after 24 weeks. Anxiety and depression were evaluated with the Hospital Anxiety and Depression scale (HADS), HRQL with the SF-36 Mental Component Summary scores (MCS) and SOC with the Sense of Coherence-13 questionnaire.

RESULTS

No baseline differences were found between groups on any outcome variable. At 24 weeks, IT and TA had significantly better values than CT on all variables. All three groups showed significant improvements from baseline on all variables, except HAD depression in CT; however, improvements were significantly greater in IT and TA than in CT. IT and TA did not differ on any outcome variable. Effect sizes were large in IT and TA for all variables and small or moderate in CT. Improvements on all variables seen after 8-weeks of IT and TA remained stable at 24 weeks and the CT group improved on HAD anxiety.

CONCLUSIONS

IT and TA seem to be more beneficial than CT in reducing anxiety, depression, and in improving quality of life and sense of coherence after 24 weeks of follow up in patients with psychological distress. More research is needed to confirm these results.

TRIAL REGISTRATION

ISRCTN trial number NCT01631500.

Effects of electro-acupuncture on personality traits in depression: a randomized controlled study

OBJECTIVE

To explore the personality-adjusting effect of electro-acupuncture treatment for depression and compared this treatment with paroxetine treatment.

METHODS

A non-blinded, randomized controlled trial was adopted. Sixty depressed patients, who met trial criteria, were randomly assigned to the treatment and the control groups. In the treatment group, electro-acupuncture treatment was used, and paroxetine treatment was used in the control group. During the 24-week study period, 12 patients dropped out and 48 patients completed the study. The Minnesota Multiple Personality Inventory (MMPI) was adopted as the evaluation tool. At the same time, the Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS) and Montgomery-Asberg Depression Rating Scale (MADRS) were used to evaluate the psychological state. Evaluations were done before and after treatment.

RESULTS

After treatment, patients' psychological state improved significantly in both groups (P<0.01). For the treatment group, within-group comparison between baseline and after 24 weeks of treatment showed that severity of depression had significantly decreased (P<0.01). MADRS and SDS scores decreased significantly (P<0.05) and MMPI subscale scores for hypochondriasis, depression, psychopathic deviate, psychasthenia, social introversion and fake decreased significantly (P<0.05). For the control group, severity of depression also decreased significantly. MADRS and SDS scores decreased significantly (P<0.05); and MMPI subscale scores for hypochondriasis, depression, hysteria, paranoia, and psychasthenia decreased significantly (P<0.05). Between-group comparison demonstrated that for the MMPI subscales paranoia and social introversion, the decrease of score was greater in the treatment group than in the control group (P<0.05). However, there were no other significant differences between the control group and the treatment group.

CONCLUSION

Electro-acupuncture is effective for treating depression and affects personality traits.

Complementary and alternative therapies as add-on to pharmacotherapy for mood and anxiety disorders: a systematic review

BACKGROUND

Depressed and anxious patients often combine complementary and alternative medicine (CAM) therapies with conventional pharmacotherapy to self-treat symptoms. The benefits and risks of such combination strategies have not been fully evaluated. This paper evaluates the risk-benefit profile of CAM augmentation to antidepressants in affective conditions.

METHODS

PubMed was searched for all available clinical reports published in English up to December 2012. Data were evaluated based on graded levels of evidence for efficacy and safety.

RESULTS

Generally, the evidence base is significantly larger for depression than for anxiety disorder. In unipolar depression, there is Level 2 evidence for adjunctive sleep deprivation (SD) and Free and Easy Wanderer Plus (FEWP), and Level 3 for exercise, yoga, light therapy (LT), omega-3 fatty acids, S-adenosylmethionine and tryptophan. In bipolar depression, there is Level 1 evidence for adjunctive omega-3s, Level 2 for SD, and Level 3 for LT and FEWP. In anxiety conditions, exercise augmentation has Level 3 support in generalized anxiety disorder and panic disorder. Though mostly well-tolerated, these therapies can only be recommended as third-line interventions due to the quality of available evidence.

LIMITATIONS

Overall, the literature is limited. Studies often had methodological weaknesses, with little information on long-term use and on potential drug-CAM interactions. Many CAM studies were not published in English.

CONCLUSIONS

While several CAM therapies show some evidence of benefit as augmentation in depressive disorders, such evidence is largely lacking in anxiety disorders. The general dearth of adequate safety and tolerability data encourages caution in clinical use.