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

Abstract

Background: Patients with post-stroke depression (PSD) usually experience anxiety, hopelessness, and insomnia, which have a negative impact on their daily activities and post-stroke rehabilitation. Acupuncture (AC), as a minimally invasive technique, has become a popular choice for improving depression symptoms. However, it is still unclear which therapy is associated with the best outcomes for PSD. In this review, we aimed to explore the impact of AC in alleviating symptoms of PSD and to evaluate the difference in effectiveness between AC combined with pharmacotherapies and various non-pharmacotherapies.

Methods: Six databases and three clinical trials registration platforms were searched from inception to March 2023. Randomized clinical trial comparing needle-based AC with pharmacotherapy, and other non-pharmacotherapy or invalid group were included. Two independent reviewers identified eligible studies, and collected data using a pre-made form. A Bayesian network meta-analysis was conducted to assess and compare different techniques using RStudio 3.6.0 with the package 'GEMTC' V.0.8.1. The primary outcome was the efficacy for PSD assessed by scales measuring depressive symptoms. The secondary outcomes were effectiveness for neurological function and the quality of life. The ranking probabilities for all treatment interventions was performed using the Surface Under the Cumulative Ranking curve (SUCRA). The risk of bias was assessed by using the Revised Cochrane Risk of Bias tool 2.

Results: Sixty-two studies, involving 5308 participants published from 2003 to 2022, were included. The results showed that compared with western medicine (WM) (defined as pharmacotherapy for PSD), AC alone or with repetitive transcranial magnetic stimulation (RTMS), Traditional Chinese medicine (TCM) alone or with WM, were superior for alleviating depression symptoms. Compared to Usual Care, AC alone or plus other therapies could significantly decrease scores on the Hamilton Depression Rating scale. According to result of SUCRA, AC plus RTMS had the highest probability of improving depressive symptoms with a probability of 49.43%.

Conclusions: The results of this study indicate that AC alone or combined with other therapies appears to be effective in improving depression symptoms of stroke survivors. Moreover, in comparison to WM, AC alone or plus RTMS, TCM, TCM with WM, or WM, were more effective in improving depression symptoms of PSD. Also, AC with RTMS seems to be the most effective with the highest probability.

Registration: This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database in November 2020 and updated in July 2021. The registration number is CRD42020218752.

Keywords: Acupuncture; Network meta-analysis; Post-stroke depression.

Fig. 1

Flow diagram outlining the guideline selection process #Cochrane Library- 1032; PubMed- 2786; EMBASE- 2204; China National Knowledge Infrastructure (CNKI) -1065; Wanfang Database- 561; Chongqing VIP Database (CQVIP) – 298

Fig. 2

The results of ROB 2 assessment for included studies

Fig. 3

The results of STRICTA assessment for included studies Note: 1a) Style of acupuncture (e.g. Traditional Chinese Medicine, Japanese, Korean, Western medical, etc.); 1b) Reasoning for treatment provided, literature sources, and/or consensus methods, with references where appropriate; 1c) Extent to which treatment was varied; 2a) Number of needle insertions per subject per session (mean and range where relevant) ; 2b) Names (or location if no standard name) of points used (uni/bilateral) ; 2c) Depth of insertion, based on a specified unit of measurement; 2d) Response sought (e.g. de qi or muscle twitch response); 2e) Needle stimulation (e.g. manual, electrical) ; 2f) Needle retention time; 2 g) Needle type (diameter, length, and manufacturer) ; 3a) Number of treatment sessions; 3b) Frequency and duration of treatment sessions; 4a) Details of other interventions administered to the acupuncture group (e.g. moxibustion, cupping, herbs, exercises); 4b) Setting and context of treatment, including instructions to practitioners, and information and explanations to patients; 5) Description of participating acupuncturists (qualification or professional affiliation, other relevant experience) ; 6a) Rationale for the control or comparator in the context of the research question, with sources that justify this choice; 6b) Precise description of the control or comparator. If sham acupuncture or any other type of acupuncture-like control is used, provide details as for Items 1 to 3 above

Fig. 4

Network plot NOTE: The estimates of mean difference of treatments in the columns versus rows presented in the lower diagonal elements (while those of the row treatments vs. column treatments are presented in the upper diagonal elements). The MD of significant difference was presented in bold font. AC, Acupuncture; AM, Acupuncture and moxibustion; TCM, Traditional Chinese medicine; WM, Western medicine; UC, Usual care; RTMS, Repetitive transcranial magnetic stimulation; CT, Cognitive therapy

Fig. 5

The forest plot for neurological impairment