Acupuncture for depression: a critique of the evidence base

Using a modified nominal group technique to develop complex interventions for a randomised controlled trial in children with symptomatic pes planus

Background

Children with symptomatic flat feet (pes planus) frequently present for care but there remains uncertainty about how best to manage their condition. There is considerable variation in practice between and within professions. We intend to conduct a three-arm trial to evaluate three frequently used interventions for pes planus (exercise and advice, exercise and advice plus prefabricated orthoses, and exercise and advice plus custom made orthoses). Each of these interventions are complex and required developing prior to starting the trial. This paper focusses on the development process undertaken to develop the interventions.

Methods

We used a modified Nominal Group Technique combining an electronic survey with two face-to-face meetings to achieve consensus on the final logic model and menu of options for each intervention. Using the Nominal Group Technique across consecutive meetings in combination with a questionnaire is novel, and enabled us to develop complex interventions that reflect contemporary clinical practice.

Results

In total 16 healthcare professionals took part in the consensus. These consisted of 11 podiatrists, two orthotists, two physiotherapists, and one orthopaedic surgeon.

Both meetings endorsed the logic model with amendments to reflect the wider psychosocial impact of pes planus and its treatment, as well as the increasing use of shared decision making in practice. Short lists of options were agreed for prefabricated and custom made orthoses, structures to target in stretching and strengthening exercises, and elements of health education and advice.

Conclusions

Our novel modification of the nominal group technique produced a coherent logic model and shortlist of options for each of the interventions that explicitly enable adaptability. We formed a consensus on the range of what is permissible within each intervention so that their integrity is kept intact and they can be adapted and pragmatically applied. The process of combining survey data with face-to-face meetings has ensured the interventions mirror contemporary practice and may provide a template for other trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06251-7.

Nurses and Holistic Modalities: The History of Chinese Medicine and Acupuncture

Holistic nursing practices holism and holistic modalities to create a healing space and optimize the healing process. Holistic nurses employ a complementary and integrative focus in their work and help patients access their greatest healing potential. This article supports that nursing professionals embrace acupuncture and alternative therapy as a great gift that inspire them to extend their already extraordinary healing power. An overview of the history of Traditional Chinese Medicine and the development and milestones of acupuncture and moxibustion in past dynasties is presented. In particular, the development of Traditional Chinese Medicine and acupuncture in the last 20 years, as well as how social and economic conditions have impacted their expansion, is discussed.

Acupuncture, Its Place in Holistic Care: Granting Access to This Critical and Timely Exposition on the Art of This Modality

Traditional Chinese medicine remains a valuable portal into an alternative way of perceiving health and illness. In view of holistic health care, this article supports nursing professionals embracing the concept and the skill of acupuncture as a great gift to empower them to expand on their already remarkable capacity in the nursing profession.

Effectiveness of acupuncture as an adjunct treatment for women with postnatal depression: a systematic review protocol

REVIEW QUESTION

The review question is: what is the best available evidence on the effectiveness of acupuncture as an adjunct treatment for women with postnatal depression?

Schizophrenia and Depression: A systematic Review of the Effectiveness and the Working Mechanisms Behind Acupuncture

OBJECTIVE

This systematic review assessed clinical evidence for the use of acupuncture as an add-on treatment in patients with depression and schizophrenia and for its underlying working mechanisms.

DATA SOURCES

Four databases (Medline, Scopus, ERIC, and the Cochrane Library) were searched with a cutoff date of March 31, 2014.

STUDY SELECTION

Systematic reviews and meta-analyses of acupuncture treatment for depression and schizophrenia were considered for inclusion. The scarcity of acupuncture research involving schizophrenia led to the inclusion of randomized controlled trials and case studies.

DATA EXTRACTION

The primary and secondary aims of this study were to evaluate the effects of acupuncture in treating patients with depression or schizophrenia and the possible working mechanisms underlying acupuncture through a systematic literature review.

DATA SYNTHESIS

The overall clinical results on using acupuncture to treat depression are promising, but only limited evidence for its effectiveness in treating schizophrenia was found. Acupuncture improves the quality of life, particularly that of sleep, in psychiatric patients. Brain research has revealed that acupuncture has a modulating and normalizing effect on the limbic-paralimbic-neocortical network (LPNN), including the default mode network. Because the LPNN is related to sleep and emotions, this might explain the improved qualities of life and sleep after acupuncture.

CONCLUSIONS

From the evidence found in this study, acupuncture seems to be an effective add-on treatment in patients with depression and, to a lesser degree, in patients with schizophrenia, but large well-designed studies are needed to confirm that evidence.

Acupuncture mechanism and redox equilibrium

Oxidative stress participates in the pathological process of various diseases. Acupuncture is a component of the health care system in China that can be traced back for at least 3000 years. Recently, increased evidences indicate that acupuncture stimulation could reduce oxidative damage in organisms under pathological state, but the exact mechanism remains unclear. This review focuses on the emerging links between acupuncture and redox modulation in various disorders, such as vascular dementia, Parkinson's disease, and hypertension, ranging from redox system, antioxidant system, anti-inflammatory system, and nervous system to signaling pathway. Although the molecular and cellular pathways studies of acupuncture effect on oxidative stress are preliminary, they represent an important step forward in the research of acupuncture antioxidative effect.

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.

Integrative medicine for treating depression: an update on the latest evidence

Integrative medicine (IntM) is a growing medical trend combining conventional medical approaches with evidence-based complementary therapies to promote well-being. Over half of individuals with depression use some form of IntM for symptom management. The purpose of the current study was to critically review the scientific evidence for IntM techniques in treating adult unipolar depression. We examined randomized controlled trials, systematic reviews, and meta-analyses published in the last one to three years using PsychINFO, PubMed, and Cochrane Library databases. The strongest evidence currently exists for mindfulness-based interventions and St. John's Wort (SJW) as monotherapies, and there is relatively strong evidence to support the use of omega-3 fatty acids and exercise as adjunct therapies. However, there remains an overall lack of methodologically rigorous research to support the efficacy of many other IntM techniques. Providers should be aware that many patients use IntM techniques for depression treatment and inquire regularly about such use.

Challenges to evaluating complex interventions: a content analysis of published papers

BACKGROUND

There is continuing interest among practitioners, policymakers and researchers in the evaluation of complex interventions stemming from the need to further develop the evidence base on the effectiveness of healthcare and public health interventions, and an awareness that evaluation becomes more challenging if interventions are complex.We undertook an analysis of published journal articles in order to identify aspects of complexity described by writers, the fields in which complex interventions are being evaluated and the challenges experienced in design, implementation and evaluation. This paper outlines the findings of this documentary analysis.

METHODS

The PubMed electronic database was searched for the ten year period, January 2002 to December 2011, using the term "complex intervention*" in the title and/or abstract of a paper. We extracted text from papers to a table and carried out a thematic analysis to identify authors' descriptions of challenges faced in developing, implementing and evaluating complex interventions.

RESULTS

The search resulted in a sample of 221 papers of which full text of 216 was obtained and 207 were included in the analysis. The 207 papers broadly cover clinical, public health and methodological topics. Challenges described included the content and standardisation of interventions, the impact of the people involved (staff and patients), the organisational context of implementation, the development of outcome measures, and evaluation.

CONCLUSIONS

Our analysis of these papers suggests that more detailed reporting of information on outcomes, context and intervention is required for complex interventions. Future revisions to reporting guidelines for both primary and secondary research may need to take aspects of complexity into account to enhance their value to both researchers and users of research.

Sleep ameliorating effects of acupuncture in a psychiatric population

The interest of psychiatric patients for complementary medicine, such as acupuncture, is stable, but effect studies in psychiatry remain scarce. In this pilot study, the effects of 3 months of acupuncture treatment on sleep were evaluated and compared between a group of patients with schizophrenia (n = 16) and a group with depression (n = 16). Healthy controls were included in order to establish reference values (n = 8). Patients with schizophrenia and depression were randomly assigned to either a waiting list or a treatment condition. The Pittsburgh Sleep Quality Inventory was completed before and after the acupuncture treatment (individualized and according to traditional Chinese medicine principles) or the waiting list condition. Both acupuncture groups showed significant lower scores on the sleep inventory, which was not the case for the waiting list condition. Moreover, it was found that the effectiveness of the acupuncture treatment was higher in the patients with schizophrenia than in the patients with depression. Acupuncture seems able to improve sleep in this convenient sample of patients with long-lasting psychiatric problems and may be a suitable and cost-effective add-on treatment for this group, particularly if conducted group-wise.

Effect and mechanism of acupuncture on Alzheimer's disease

Alzheimer's disease is the most common form of dementia diagnosed in the aging population worldwide. The cause of Alzheimer's is still not clear. There is no cure for the disease and current treatments are only symptomatic relieve. The search for new treatment is made ever more urgent due to increasing population aging. Acupuncture has been in practice in China for more than 3000 years and used to treat a wide variety of conditions including cardiovascular and psychiatric diseases, acute, and chronic pain. In this chapter, we review recent development on the effects and mechanisms of acupuncture on Alzheimer's disease. In Alzheimer's animal models, acupuncture stimulation at acupoints enhances cholinergic neurotransmission, trophic factor releasing, reduces apoptotic and oxidative damages, improves synaptic plasticity and decreases the levels of Aβ proteins in the hippocampus and relevant brain regions. The biochemical modulations by acupuncture in the brains of Alzheimer's models are correlated with the cognitive improvement. In Alzheimer's patients, functional brain images demonstrated that acupuncture increased in the activity in the temporal lobe and prefrontal lobe which are related to the memory and cognitive function. Although only a few acupuncture clinical studies with a small number of participants are reported, they represent an important step forward in the research of both acupuncture and Alzheimer's. Translation of acupuncture research in animal model studies into the human subjects will undoubtedly enhance acupuncture efficacy in clinical study and treatment which could eventually lead to a safer, well-tolerated and inexpensive form of care for Alzheimer's patients.

The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond

STUDY QUESTION

What is the current literature on the safety and efficacy of selective serotonin reuptake inhibitor (SSRI) use in infertile women?

SUMMARY ANSWER

There is little evidence that infertile women benefit from taking an SSRI, therefore they should be counseled appropriately about the risks and be advised to consider alternate safer treatments to treat depressive symptoms.

WHAT IS KNOWN ALREADY

SSRI use is associated with possible reduced infertility treatment efficacy as well as higher rates of pregnancy loss, preterm birth, pregnancy complications, neonatal issues and long-term neurobehavioral abnormalities in offspring.

STUDY DESIGN, SIZE, DURATION

Review of existing literature.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We conducted a review of all published studies that evaluate females with depressive symptoms who are taking antidepressant medications and who are experiencing infertility.

MAIN RESULTS AND THE ROLE OF CHANCE

Antidepressant use during pregnancy is associated with increased risks of miscarriage, birth defects, preterm birth, newborn behavioral syndrome, persistent pulmonary hypertension of the newborn and possible longer term neurobehavioral effects. There is no evidence of improved pregnancy outcomes with antidepressant use. There is some evidence that psychotherapy, including cognitive-behavioral therapy as well as physical exercise, is associated with significant decreases in depressive symptoms in the general population; research indicates that some forms of counseling are effective in treating depressive symptoms in infertile women.

LIMITATIONS, REASONS FOR CAUTION

Our findings are limited by the availability of published studies in the field, which are often retrospective and of small size.

WIDER IMPLICATIONS OF THE FINDINGS

Practitioners who care for infertility patients should have a thorough understanding of the published literature so that they can adequately counsel their patients.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Acupuncture for depression: exploring model validity and the related issue of credibility in the context of designing a pragmatic trial

INTRODUCTION

Evaluating care that is not credible to its practitioners or patients will result in a gap between evidence and practice and the potential value, or harm, of the intervention may be underestimated. Our aim was to develop a pragmatic trial that would have better model validity and credibility than trials to date in this clinical area.

METHODS

In-depth interviews; a nominal consensus technique and five arm pilot trial conducted in UK primary care using counseling and usual general practitioner (GP) care as comparisons for acupuncture.

FINDINGS

Patients with long standing, severe illness that had not responded, or partially responded to conventional treatments may be interested in using acupuncture and participating in a trial. Using a database method to recruit, pilot trial patients were mostly severely depressed (87.5%); chronically ill (60% with 3+ previous episodes), with high levels of comorbidity, and medication use. Acupuncture was as credible to pilot trial participants as usual GP care and more credible than counseling: most patients (62.5%) preferred to be allocated to acupuncture, rating it more highly at baseline than counseling or usual GP care as potentially able to benefit their depression (P = 0.002). Disparities were identified in the working models of acupuncturists and counselors that suggest inherent differences between interventions in terms of the process and intended potential outcomes of therapy, as well as the interaction between patients and therapists.

CONCLUSION

The Medical Research Council (MRC) framework with its phased, mixed method approach has helped to develop research that has better model validity than trials to date in this field. The next phase of research will need to involve acupuncture and counseling practitioners to help researchers to develop realistic and credible care packages for a full-scale trial, where patients are likely to be severely and chronically ill.