The Role of Acupuncture in the Management of Insomnia as a Major or Residual Symptom Among Patients With Active or Previous Depression: A Systematic Review and Meta-Analysis

Abstract

BackgroundDue to concerns about risks associated with antidepressants and/or hypnotics, complementary therapies such as acupuncture have been sought by patients with active or previous depression to manage insomnia. This systematic review aimed to clarify if acupuncture is effective and safe enough to be recommended as an alternative or adjuvant therapy to standard care in ameliorating concomitant or residual insomnia, two types of insomnia associated with depression.MethodsRandomized controlled trials (RCTs) of depression-related insomnia (DI) treatment via acupuncture vs. waitlist-control or placebo-/sham-acupuncture and RCTs of DI treatment via acupuncture alone or combined with standard care [Western pharmacotherapy and/or cognitive-behavioral therapy (CBT)] vs. standard care alone were searched for from seven databases from inception to December 2021. Cochrane criteria were followed.ResultsTwenty-one studies involving 1,571 participants were analyzed. For insomnia as a major symptom of active depression, meta-analyses suggested that acupuncture significantly reduced the global scores of both the Pittsburg Sleep Quality Index (PSQI) [MD = −3.12, 95% CI (−5.16, −1.08), p < 0.01] and Hamilton Depression Scale (HAMD) [SMD = −2.67, 95% CI (−3.51, −1.84), p < 0.01], in comparison with placebo-acupuncture. When compared with conventional pharmacotherapy (antidepressants and/or hypnotics), the results favored acupuncture in decreasing PSQI [MD = −1.17, 95% CI (−2.26, −0.08), p = 0.03] and HAMD [SMD = −0.47, 95% CI (−0.91, −0.02), p = 0.04]. Acupuncture was comparable to conventional pharmacotherapy in reducing scores of each domain of PSQI. For insomnia as a residual symptom of previous or partially remitted depression, acupuncture conferred a very limited, non-significant therapeutic advantage against sham-/placebo-acupuncture. Whether acupuncture has an add-on effect to conventional pharmacotherapy in this type of insomnia has not been investigated. Also, no study was available to address the efficacy differences between acupuncture and CBT or the synergistic effect of these two therapies.ConclusionsThere is a low to moderate level of evidence supporting acupuncture as a safe and effective remedy alternative to or adjuvant to conventional pharmacotherapy (antidepressant and/or hypnotic) in improving insomnia and other depression symptoms among patients with active depression. Furthermore, the patients' complaint of disrupted sleep continuity is most likely to benefit from acupuncture. The benefit of acupuncture on residual insomnia associated with previous or partially remitted depression is limited. Future acupuncture studies need to consider applying optimal dosage and addressing deficiencies in trial quality.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021269880, PROSPERO, identifier: CRD42021269880.

A Systematic Review and Meta-Analysis Protocol to Establish How Common Clinical Acupoint Stimulation-Related Therapies Should Be Used for Managing Insomnia

“…In addition to acupuncture and acupressure, ASRTs have now evolved into numerous treatment techniques driven by clinical need, with acupoint selection varying from practitioner to practitioner. While several clinical common ASRTs for insomnia have been evaluated in previous systematic reviews, [45][46][47][48][49][50][51][52][53] in the face of such a wide range of ASRTs, there is no conclusion on how ASRT clinicians should manage insomnia in clinical practice. To develop guidelines and further drive future clinical practice and research, a more thorough and comprehensive evaluation of all the existing literature is required.…”

“…43,44 Numerous systematic reviews have also reported that the efficacies of these common clinical ASRTs for primary insomnia and comorbid insomnia were higher than that of routine care, placebo acupuncture, or waiting list controls. [45][46][47][48][49][50][51][52][53] However, the generalizability of these findings was constrained by the fact that the quality of the available literature is generally poor and these meta-analyses concentrated on a particular form of insomnia and/or a single therapy approach.…”

Acupuncture for comorbid depression and insomnia in perimenopause: A feasibility patient-assessor-blinded, randomized, and sham-controlled clinical trial

“…The selection of acupoints was on the basis of our team's review and experts' advice. Our previous systematic review indicated that the most frequently used acupoints for depression-related insomnia were EX-HN3, GV20 and SP6 ( 13 ). Given the recruited participants were within the “Depression of Liver and Deficiency of Kidney ” pattern, we chose LR3 and KI3, which was Yuan - Source acupoint of Liver Meridian of Foot-Jueyin and Kidney Meridian of Foot-Shaoyin , respectively.…”

“…Sedatingantidepressant agent (e.g., Mirtazapine, Trazodone, Agomelatine) are a reasonable option for treating comorbid depression and insomnia (12). However, these psychotropic agents can create dependence and also have adverse effects (AEs) causing dry mouth, nausea, dizziness, increased appetite and rapid weight gain, constipation, and sexual dysfunction (13). Hormonal replacement therapy (HRT) has been a routine and effective strategy for the management of perimenopausal Abbreviations: AEs, adverse events; AES, Acupuncture Expectancy Scale; symptoms including PMD and PMI (14,15).…”

“…It involves insertion of one or several thin, solid, metallic needles through the skin into underlying tissues at different depths and at strategic points on the body (called “acupoints”) to produce a desired therapeutic effect ( 18 ). After insertion, the needles are usually manipulated in an up-and-down and rotating movement (i.e., manual acupuncture) or connected to a battery-operated device delivering electric microcurrent in high- or low-frequency (i.e., electroacupuncture), or a combination of both techniques ( 13 ). Acupuncture is commonly used for acute and chronic pain relief, indigestion, anxiety, insomnia, fertility and a broad range of other health conditions ( 19 , 20 ).…”