Clinical effects and safety of electroacupuncture for the treatment of post-stroke depression: a systematic review and meta-analysis of randomised controlled trials

Integrative-interpersonal dynamic therapy for poststroke depression (INID): study protocol of a randomised controlled pilot trial

INTRODUCTION

Depression is the most frequent psychiatric disorder following stroke, affecting about one-third of stroke survivors. Patients experience poorer recovery, lower quality of life and higher mortality compared with stroke survivors without depression. Despite these well-known malign consequences, poststroke depression (PSD) is regarded underdiagnosed and undertreated. Evidence of beneficial effects of psychotherapy to treat PSD remains scarce and inconclusive and is limited by heterogeneity in design, content and timing of the intervention. This pilot study aims to assess the feasibility of a newly developed integrative-interpersonal dynamic PSD intervention in an outpatient setting and provide a first estimation of the potential effect size as basis for the sample size estimation for a subsequent definite trial.

METHOD AND ANALYSIS

Patients will be recruited from two German stroke units. After discharge from inpatient rehabilitation, depressed stroke survivors will be randomised to short-term psychotherapy (12 weeks, ≤16 sessions) or enhanced treatment as usual. The manualised psychotherapy integrates key features of the Unified Psychodynamic and Cognitive-Behavioural Unified Protocol for emotional disorders and was adapted for PSD. Primary endpoints are recruitment feasibility and treatment acceptability, defined as a recruitment rate of ≥20% for eligible patients consenting to randomisation and ≥70% completion-rate of patients participating in the treatment condition. A preliminary estimation of the treatment effect based on the mean difference in Patient Health Questionnaire-9 (PHQ-9) scores between intervention and control group six months poststroke is calculated. Secondary endpoints include changes in depression (PHQ-9/Hamilton Depression Scale) and anxiety (Generalised Anxiety Disorder 7) of all participants across all follow-ups during the first year poststroke.

ETHICS AND DISSEMINATION

The INID pilot study received full ethical approval (S-321/2019; 2022-2286_1). Trial results will be published in a peer-reviewed journal in the first half of 2025. One-year follow-ups are planned to be carried out until summer 2025.

TRIAL REGISTRATION NUMBER

DRKS00030378.

A pilot controlled trial of a combination of electroacupuncture and psychological intervention for post-stroke depression

OBJECTIVE

This study was to investigate effects of a combination of electroacupuncture (EA) and psychological intervention (PI) for post-stroke depression (PSD) and provide treatment suggestions METHODS: In a single-blind, randomized controlled trial, 49 patients with PSD were randomly divided into two groups, PI group (n = 23) and PI+EA group (n = 26). PI group received PI 2 times a week by a professional psychologist. In addition to PI treatment, PI+EA group was treated with EA at GB13 and HT7, 30 min, 5 times a week, 4 weeks as a course of treatment, a total of 12 weeks. The 17-item Hamilton Rating Scale for Depression (HAMD-17) and Lo Knapp Ron J's sleep score table were measured before treatment, 4 weeks, 8 weeks and 12 weeks after treatment.

RESULTS

After 12 weeks of PI or PI+EA therapy, 42 of 49 patients were effective and 7 were ineffective, with an effective rate of 85.7 %. Among them, the effective rate of PI group alone was 78.3 %, and the effective rate of PI+EA group was 92.3 %. Compared with values of PI, HAMD-17 values at 8 weeks of PI+EA treatment were significantly decreased (P < 0.01). At the same time, Sleep Score table was significantly decreased after PI+EA treatment (P < 0.05). Incidence of adverse events was not different in the two groups CONCLUSION: A combination of EA and PI maybe an effective and safe treatment option for PSD, which is statistically more significant than PI treatment alone. Due to small samples involved in this pilot study, further research is needed to see whether a combination of EA and PI will match the results of this pilot study.

Effectiveness and Safety of Electroacupuncture for Depression: A Systematic Review and Meta-Analysis

Purpose. The purpose of this systematic review and meta-analysis was to comprehensively evaluate the efficacy and safety of electroacupuncture as an effective adjunctive therapy for patients with depression. Methods. Randomized controlled trials (RCTs) about the treatment of depression by electroacupuncture therapy from inception to September 2021 were searched and collected in eight databases. HAMD, SDS, and Adverse Reactions were used as outcome indicators. The quality of relevant articles was evaluated using the Cochrane Collaboration’s risk of bias tool. The quality of evidence for each outcome was assessed through the Grading of Recommendations Assessment and the Development and Evaluation approach. Stata 15.0 software was used for data analysis. Results. A total of 16 depression-related RCTs were included in this meta-analysis. For the main outcome, electroacupuncture significantly reduced HAMD scores (I2:0.0%, SMD: −2.28% (95% CI−3.16 to −1.39)), and the quality of evidence was moderate. The improvement effect of electroacupuncture plus antidepressants was better than that of western drugs in patients with depression (I2:26.2%, SMD: −1.18% (95% CI−1.42 to −0.94)), and the quality of evidence was moderate. Electroacupuncture significantly reduced HAMD scores without significant heterogeneity (I2:0.0%, SMD: −3.76% (95%CI−5.78−1.73)). Studies with very low quality of evidence found that electroacupuncture was as effective as antidepressants in reducing SDS scores (I2:36.4%, WMD: −1.15% (95%CI−2.93–0.63)), and electroacupuncture was found to be more effective than sham electroacupuncture stimulation as well. Moderate quality evidence showed no statistical difference between electroacupuncture plus antidepressants/electroacupuncture and antidepressants (I2:0%, RR:1.05% (95%CI 0.73 to 1.53)). Conclusions. Our meta-analysis shows that electroacupuncture reduces HAMD scores. It is suggested to use electroacupuncture plus antidepressants to improve the curative effect and effectively reduce drug side effects.

A Narrative Review on the Non-Pharmacologic Interventions in Post-Stroke Depression

Stroke is a major cause of death and disability globally. Post-stroke depression (PSD) is a major driver for poor recovery and poor quality of life with extra burden for the patient and the caregiver. We have previously shown the inflammatory basis of PSD with associated bioenergetic failure, disruption of the blood-brain barrier, cell death, and persistent maladapted inflammation, making the PSD a norm rather than the exception, highlighting the unmet need for therapeutic intervention in PSD across the recovery trajectory. In this era, various interventions are focused on pharmacotherapy; however, non-pill-based medication should also be explored as post-stroke patients are likely to suffer from the adverse effects of polypharmacy. This narrated review explores the status of non-pharmacological interventions in managing PSD. We performed a PubMed search using pre-specified keywords looking at various non-pharmacologic approaches for the management of PSD. Worldwide, approaches such as non-invasive brain stimulation, behavioral and psychosocial therapy, as well as exercise, acupuncture, music, literature, and art therapies are available as monotherapy or adjunctive treatment for PSD. While current literature shows convincing results on the benefits of non-pharmacologic interventions, more robust studies are necessary to determine its utility in PSD.

Efficacy and safety of electroacupuncture for post-stroke depression: a randomized controlled trial

OBJECTIVE

The objective of this study is to evaluate the efficacy and safety of electroacupuncture (EA) treatment for post-stroke depression (PSD).

METHODS

This study was a single-center, single-blinded, parallel-arm randomized controlled trial. In total, 65 patients with PSD were randomly allocated into EA and sham EA groups. Treatment was administered at GV20, Sishencong, SP6, LR3 and BL18 in both groups. The EA group received EA treatment, while the sham EA group received sham EA treatment using the Park device. Treatment was given three times a week for 4 weeks. The primary outcome was the Hamilton Rating Scale for Depression (HRSD). Secondary outcomes included the Zung Self-Rating Depression Scale (SDS), National Institutes of Health Stroke Scale (NIHSS), Barthel Daily Living Index (BI) and depression scale of traditional Chinese medicine (TCM). Primary and secondary outcomes were assessed at baseline, week 2 after treatment, week 4 after treatment and week 8 of follow-up. Safety assessment was conducted at each visit for 4 weeks of treatment.

RESULTS

Significant differences in HRSD, SDS, NIHSS, BI and TCM scale scores were found in the EA group before and after acupuncture treatment (all p < 0.001). Compared with the sham EA group, HRSD scores improved significantly in the EA group at the end of week 2 (F = 31.33, p < 0.001), week 4 (F = 35.58, p < 0.001) and week 8 after treatment onset (F = 25.03, p < 0.001). Similarly, significant improvements were observed in SDS, NIHSS and BI scores. Two participants in the EA group suffered a local hematoma, while no adverse events were reported in the sham EA group.

CONCLUSION

EA appears to be an efficacious and safe treatment for PSD. According to our results, EA may alleviate depressive symptoms, and improve neurological function and capabilities with respect to activities of daily living (ADLs).

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-17012610 (Chinese Clinical Trial Registry).

Electroacupuncture as a rapid-onset and safer complementary therapy for depression: A systematic review and meta-analysis

BACKGROUND

Electroacupuncture (EA) is a promising therapy for depression. However, a comprehensive review of EA for depression is needed.

METHODS

We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA 2020) guidelines to evaluate the efficacy and safety of EA for depression. Potentially relevant trials and reviews were searched in MEDLINE, EMBASE, PsycINFO, and CENTRAL from inception to March 2022. EA alone and combined with other therapy were eligible for inclusion. The severity of depression during and after treatment and the number of adverse events were assessed as outcomes. Risk of bias (ROB) evaluation, subgroup analysis, sensitivity analysis, reporting bias assessment, and GRADE system evaluation were also conducted.

RESULTS

Thirty-four trials were included. The overall ROB was medium. Low-quality evidence showed that the efficacy of EA was not less than that of antidepressants [EA + selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs)] and manual acupuncture (MA). EA and EA + SSRIs had better efficacy than SSRIs alone in decreasing the severity of depression during the early treatment. Moderate-quality evidence also showed that EA and EA + SSRIs were safer than SSRIs alone. Sensitivity analysis was mostly not feasible. Major publication bias was unlikely.

CONCLUSION

These results indicate that the efficacy of EA is not less than that of antidepressants and MA. Moreover, EA and EA + SSRI treatments show a more rapid onset and greater safety than SSRIs. More high-quality trials are needed for further confirmation.

SYSTEMATIC REVIEW REGISTRATION

[www.crd.york.ac.uk/prospero/display_ record.php?RecordID=329143], identifier [CRD42022329143].

Effectiveness and safety of manual acupuncture therapy in patients with post-stroke depression: a protocol for a systematic review and meta-analysis

INTRODUCTION

Acupuncture is widely used on the rehabilitation of stroke survivors, including hemiplegia, constipation, emotional disorders and so on. Although the effectiveness of manual acupuncture therapy on post-stroke depression (PSD) has been confirmed by multiple randomised controlled trials, there were few meta-analyses focused on the connection between different techniques, durations or other detailed operations of manual acupuncture and their effectiveness of improving the depression severity and quality of life for patients with PSD.

METHODS AND ANALYSIS

A systematic search will be performed on English databases (PubMed, the Cochrane Library, Medline and Embase), Chinese databases (China National Knowledge Infrastructure, WanFang Data, VIP and Chinese biomedical databases) and Japanese databases (Japan Science and Technology Agency and CiNii). The retrieval time limit will be from the establishment of the database to November 2020. Two researchers will independently screen the literature works, extract data and evaluate the quality of the included studies. Meta-analysis will be conducted by using STATA V.14.0 and Review Manager V.5.3.

ETHICS AND DISSEMINATION

The results of this meta-analysis will be disseminated through publication in peer-reviewed journals or conference presentations. The data used in this meta-analysis will not contain individual patient data; therefore, ethical approval is not required.

PROSPERO REGISTRATION NUMBER

CRD42020222825.

Depression, Anxiety, and Suicide After Stroke: A Narrative Review of the Best Available Evidence

Depression and anxiety each affect around 1 in 3 people during the first year after a stroke. Suicide causes the death of about 3 to 4/1000 stroke survivors during the first 5 years. This narrative review describes the best available evidence for the epidemiology of depression, anxiety, and suicide; their prevention; and the treatment of anxiety and depression. We conclude with directions for future research.

Comparison between acupuncture and antidepressant therapy for the treatment of poststroke depression: Systematic review and meta-analysis

BACKGROUND

In this paper, a systematic review and meta-analysis of published randomized controlled trials (RCTs) was conducted to compare the efficacies of acupuncture and antidepressant therapy for the treatment of poststroke depression (PSD).

METHODS

The research team searched RCTs published on PubMed; Medline; Cochrane library; Chinese National Knowledge Infrastructure (CNKI); Wanfang; Embase; Scopus, and Sinomed from their respective establishments to January 2019. We evaluated the Hamilton Depression Rating Scale (HAMD) scores, Treatment Emergent Symptom Scale (TESS) scores, National Institute of Health Stroke Scale (NIHSS) scores, and total clinical efficacy using fixed effects models.

RESULTS

Fourteen RCTs, representing a total of 1124 patients, were studied. Results showed that acupuncture was more effective in improving HAMD scores at 3 weeks after administration (mean difference [MD] = -1.17, 95%CI = -2.18 to -0.16), at 4 weeks (MD = -4.44, 95% CI = -5.64 to -3.23), at 6 weeks (MD = -1.02, 95% CI = -1.68 to -0.36), and at 8 weeks (MD = -4.33, 95% CI = -4.96 to -3.70). Similarly, acupuncture more dramatically decreased NIHSS scores (MD = -2.31, 95% CI = -2.53 to -2.09), and TESS scores (MD = -4.70, 95% CI = -4.93 to -4.48) than conventional Western medicinal therapy. Further, the total clinical efficacy in the acupuncture group was significantly higher than in the antidepressants group (risk ratio [RR] = 1.15, 95% CI = 1.08-1.21).

CONCLUSIONS

The results of this study suggest that acupuncture not only can reduce the severity of PSD, but also has significant effects on decreasing the appearance of other adverse events.

Acupuncture for post-stroke depression: a systematic review and meta-analysis

Background

Acupuncture for post-stroke depression (PSD) has been evolving, but uncertainty remains. To assess the existing evidence from randomized clinical trials (RCTs) of acupuncture for PSD, we sought to draw conclusions by synthesizing RCTs.

Methods

An exhaustive literature search was conducted in seven electronic databases from their inception dates to April 19, 2020, to identify systematic reviews (SRs) and meta-analyses (MAs) on this topic. The primary RCTs included in the SRs/MAs were identified. We also conducted a supplementary search for RCTs published from January 1, 2015, to May 12, 2020. Two reviewers extracted data separately and pooled data using RevMan 5.3 software. The quality of evidence was critically appraised with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system.

Results

A total of 17 RCTs involving 1402 patients were included. Meta-analysis showed that participants who received a combination of acupuncture and conventional treatments exhibited significantly lower scores on the HAM-D₁₇, HAM-D₂₄ and HAM-D (MD, − 5.08 [95% CI, − 6.48 to − 3.67], I² = 0%), (MD, − 9.72 [95% CI, − 14.54 to − 4.91], I² = 65%) and (MD, − 2.72 [95% CI, − 3.61 to − 1.82], respectively) than those who received conventional treatment. However, there was no significant difference in acupuncture versus antidepressants in terms of the 17-item, 24-item and HAM-D scales (MD, − 0.43 [95% CI, − 1.61 to 0.75], I² = 51%), (MD, − 3.09 [95% CI, − 10.81 to 4.63], I² = 90%) and (MD, − 1.55 [95% CI, − 4.36 to 1.26], I² = 95%, respectively). For adverse events, acupuncture was associated with fewer adverse events than antidepressants (RR, 0.16 [95% CI, 0.07 to 0.39], I² = 35%), but there was no significant difference in the occurrence of adverse events between the combination of acupuncture and conventional treatments versus conventional treatments (RR, 0.63 [95% CI, 0.21 to 1.83], I² = 38%). The quality of evidence was low to very low due to the substantial heterogeneity among the included studies.

Conclusions

The current review indicates that acupuncture has greater effect on PSD and better safety profile than antidepressants, but high-quality evidence evaluating acupuncture for PSD is still needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03277-3.

Therapeutic effect of Chinese herbal medicines for post-stroke depression: A meta-analysis of randomized controlled trials

BACKGROUND

Whether the addition of Chinese herbal medicine (CHM) in routine western medicines for post-stroke depression yields additional therapeutic effects still remains to be controversial. This study aimed to assess the efficacy and safety of combination of CHM with routine western medicines versus routine western medicines alone in patients with post-stroke depression (PSD).

METHODS

Electronic databases such as PubMed, EmBase, Cochrane library, and China National Knowledge Infrastructure were systematically searched from inception till October 2019. Studies designed as randomized controlled trials (RCTs) and that investigated the therapeutic effects of CHM plus routine western medicines (CHM group) versus routine western medicines alone (control group) in PSD patients were eligible. The relative risk (RR) and weighted mean difference (WMD) with 95% confidence interval (CI) were used to assess the categories and continuous data using random-effects model. Software STATA was applied to perform statistical analysis (Version 10.0; StataCorp, TX,).

RESULTS

A total of 18 RCTs involving a total of 1,367 PSD patients were selected for final analysis. The effective rate in CHM group was significantly higher than that in control group (RR: 1.18; 95%CI: 1.12-1.24; P < .001). Moreover, patients in CHM group showed association with lower Hamilton Depression Rating Scale (WMD: -3.17; 95%CI: -4.12 to -2.22; P < .001) and Scandinavian Stroke Scale (WMD: -3.84; 95%CI: -5.73 to -1.96; P < .001) than those in control group. Furthermore, patients in CHM were associated with high level of Barthel Index than those in control group (WMD: 11.06; 95%CI: 4.01 to 18.10; P = .002). Finally, patients in CHM group had lower risk of gastrointestinal (RR: 0.49; 95%CI: 0.31-0.77; P = .002) and neurological (RR: 0.50; 95%CI: 0.33-0.75; P = .001) adverse events than those in control group.

CONCLUSIONS

The study findings revealed that addition of CHM to routine therapies could improve the therapeutic effects and reduce gastrointestinal or neurological adverse events.

Electroacupuncture Ameliorates Depressive-Like Behaviors in Poststroke Rats via Activating the tPA/BDNF/TrkB Pathway

BACKGROUND

Electroacupuncture (EA) is a form of physical therapy that has been widely used in clinical practice in China. Post-stroke depression (PSD) is the most common neuropsychiatric complication after stroke. EA has been shown to have beneficial effects on PSD patients. However, the potential mechanism underlying the protective effects of EA on PSD remains unclear. Here, we investigated whether tissue plasminogen activator (tPA)/brain-derived neurotrophic factor (BDNF)/tyrosine kinase receptor B (TrkB) signaling pathway participates in the therapeutic effects of EA in a rat PSD model.

METHODS

Experimental PSD was induced by combining middle cerebral artery occlusion (MCAO) with chronic unpredictable mild stimulation (CUMS) in adult male rats. Bodyweight gain, neurological score, sucrose preference, and open field test were determined at 0, 7, 14, and 35 days after completing MCAO. The protein expressions of tPA, precursor BDNF (proBDNF), mature BDNF (mBDNF), and TrkB were measured by immunofluorescence and Western blot analysis. The tPA inhibitor plasminogen inhibitor-1 (PAI-1) was used to explore whether tPA plays a crucial role in the protective effects of EA on PSD.

RESULTS

Compared with the sham rats, the PSD rats showed decreased bodyweight, deteriorated neurological score, and significant depressive-like behaviors. EA remarkably reversed bodyweight loss, neurological deficit, and depressive-like behaviors in PSD rats. Immunofluorescence staining and Western blot analysis showed that PSD-induced decreased expression of tPA, mBDNF, and TrkB were prevented by EA. Furthermore, we found that the effects of EA against PSD-induced depressive-like behaviors were abolished by PAI-1, the specific inhibitor of tPA.

CONCLUSION

Our results suggest that the improvement in depressive-like behaviors induced by EA is likely achieved via activation of the tPA/BDNF/TrkB pathway.

Post-stroke depression: Chaos to exposition

Cerebral ischemia contributes to significant disabilities worldwide, impairing cognitive function and motor coordination in affected individuals. Stroke has severe neuropsychological outcomes, the major one being a stroke. Stroke survivors begin to show symptoms of depression within a few months of the incidence that overtime progresses to become a long-term ailment. As the pathophysiology for the progression of the disease is multifactorial and complex, it limits the understanding of the disease mechanism completely. Meta-analyses and randomized clinical trials have shown that intervening early with tricyclic antidepressants and selective serotonin receptor inhibitors can be effective. However, these pharmacotherapies possess several limitations that have given rise to newer approaches such as brain stimulation, psychotherapy and rehabilitation therapy, which in today's time are gaining attention for their beneficial results in post-stroke depression (PSD). The present review highlights numerous factors like lesion location, inflammatory mediators and genetic abnormalities that play a crucial role in the development of depression in stroke patients. Further, we have also discussed various mechanisms involved in post-stroke depression (PSD) and strategies for early detection and diagnosis using biomarkers that may revolutionize treatment for the affected population. Towards the end, along with the preclinical scenario, we have also discussed the various treatment approaches like pharmacotherapy, traditional medicines, psychotherapy, electrical stimulation and microRNAs being utilized for effectively managing PSD.

Effects of electroacupuncture therapy for depression: Study protocol for a multicentered, randomized controlled trial

INTRODUCTION

As a major public health problem, depression has a negative impact on individuals and society. The aim of this well-designed trial is to evaluate the efficacy and safety of electroacupuncture (EA) treatment for depression.

METHODS/DESIGN

A 3-arm parallel, nonblinded, randomized controlled trial will be performed in 4 hospitals (centers). A total of 144 participants will be divided into 3 groups: EA group, manual acupuncture (MA) group, and western medicine group. Participants in EA group and MA group will receive 12 sessions of acupuncture treatment for 4 weeks. Participants allocated to western medicine group will only take 20 mg fluoxetine orally per day for 4 weeks. The primary outcome is Hamilton Depression Scale. Secondary outcomes are Self-Rating Depression Scale, Depression Scale of traditional Chinese medicine (Depression Scale of Traditional Chinese Medicine), brain fMRI and blood biomarkers including neurotransmitters serotonin, dopamine, noradrenaline, inflammatory cytokines inerleukin (IL)-1β, tumor necrosis factor-α, IL-6, and neurotrophin BDNF. All the outcomes will be assessed at baseline, 4 weeks after EA treatment onset and 6-month follow-up.

DISCUSSION

The results of this trial will verify the efficacy and safety of EA treatment for depressive patients and provide acupuncturists and clinicians with robust clinical evidence.

TRIAL REGISTRATION

Chinese Clinical Trial Registry identifier: ChiCTR1900023420. Version 1. Registered on 26 May 2019. http://www.chictr.org.cn/edit.aspx?pid=37621&htm=4.

The efficacy and safety of electroacupuncture against urinary incontinence after stroke: A protocol for systematic review and meta analysis

BACKGROUND

Urinary incontinence (UI) is still a persistent challenge in many stroke survivors, affecting the quality of life and emotional being of these individuals. Numerous studies have demonstrated the curative effect of electroacupuncture on post-stroke incontinence, however they were mired with questionable quality and inconsistencies in safety and efficacy. Therefore, the main objective of this meta-analysis is to provide a comprehensive evaluation of the efficacy and safety of electroacupuncture against urinary incontinence after stroke, with a view of providing more reliable evidence-based solutions for UI.

METHODS

A systematic literature search will be conducted using PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and 4 Chinese databases from inception to June 2020 to identify randomized control trials that report on electroacupuncture against urinary incontinence after stroke. Two reviewers will independently identify eligible studies and extract data. The risk of bias of the included randomized control trials will be evaluated according to the Cochrane tool. Risk ratio and 95% confidence intervals will be used to estimate the efficacy of treatment,. and the grading of recommendations, assessment, development, and evaluation approach to rate the certainty of evidence. The statistical heterogeneity will be evaluated by Cochran's Q and the I. Data will be analyzed using Stata software (Version 13.0, Stata Corp, College Station, TX, USA).

RESULTS

This study will provide a comprehensive evaluation of the efficacy and safety of electroacupuncture against UI after stroke, with a view of providing more reliable evidence-based solutions for UI.

ETHICS AND DISSEMINATION

This work synthesises evidence from previously published studies and does not require ethics review or approval. A manuscript describing the findings will be submitted for publication in a peer-reviewed scientific journal.

INPLASY REGISTRATION NUMBER

INPLASY202050073.

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.

Overview of systematic reviews with meta-analyses on acupuncture in post-stroke cognitive impairment and depression management

Background: Acupuncture has been using as an alternative non-pharmacological therapy in the management of post stroke depression and cognitive impairment but its effectiveness and safety remain controversial. We conducted an overview of systematic reviews with meta-analyses to evaluate the evidence on the effect of acupuncture in the treatment of stroke with conventional medicine intervention. Methods: Systematic reviews summarized the treatment effects of acupuncture for post stroke cognitive impairment and post stroke depression were considered eligible. Methodological quality of included systematic reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). Results: Four systematic reviews on post stroke cognitive impairment and ten systematic reviews on post stroke depression with good methodological quality were included. Meta-analyses revealed that acupuncture plus cognitive rehabilitation; and acupuncture or moxibustion plus cognitive rehabilitation, versus cognitive rehabilitation demonstrated statistically significant increase in Mini-Mental State Examination scores in compared to cognitive rehabilitation after 4 weeks treatment [Pooled weighted mean difference (WMD) = 3.14, 95% confidence interval (CI) = 2.06 to 4.21, I2 = 36%]; and (Pooled WMD = 3.22, 95% CI = 2.09 to 4.34, I2 = 0%). Furthermore, acupuncture versus antidepressant demonstrated statistically significant improve depression measured by increasing in 17-item Hamilton Depression Rating Scale in comparing to cognitive rehabilitation after 2 weeks treatment (Pooled WMD= -2.34, 95% CI= -3.46 to -1.22, I2 = 5%). Acupuncture usage was not associated with increased risk of adverse events. Conclusions: Acupuncture is safe and improves cognitive function and depressive disorder without obvious serious adverse events for post stroke patients.

Antidepressant, anti-inflammatory, and antioxidant effects of electroacupuncture through sonic hedgehog-signaling pathway in a rat model of poststroke depression

Background: Poststroke depression (PSD) is the most frequent psychological sequela after stroke. Electroacupuncture (EA) treatment is effective for PSD. The study aimed at clarifying the mechanisms of EA's antidepressant effects in a PSD rat model. Methods: We used middle cerebral artery occlusion to establish the rat model of PSD. Tests of sucrose preference and locomotor activity were performed to examine depressive-like behaviors. We measured malondialdehyde, GSH, SOD, IL6, IL1β, TNFα, and 5HT with ELISA. The hippocampal Shh-signaling pathway was assessed by Western blot. Results: EA significantly decreased sucrose preference and locomotor activities of PSD rats, reduced IL6, TNFα, increased GSH, and upregulated 5HT, and also slightly reduced IL1β and malondialdehyde, all of which were measured with ELISA. The Shh-signaling pathway assessed by Western blotting was activated by EA. Those changes were inhibited by the Shh-pathway inhibitor cyclopamine. Conclusion: EA effectively alleviated depressive-like behaviors in PSD by suppressing inflammation and oxidative stress through activation of the Shh-signaling pathway.