Inadequate Evidence for Acupuncture as an Alternative or Adjunct to Antidepressants/Psychotherapy for Postpartum Depression: A Bayesian Systematic Review and Network Meta-Analysis

Abstract

Background: Acupuncture is popular in the treatment of mental illness. This study determined its feasibility and role in managing postpartum depression (PPD) using a network meta-analysis.

Methods: We systematically searched seven databases up to May 2024 for randomized controlled trials (RCTs) appraising acupuncture's efficacy and safety against waitlist-control, placebo, standard control, or as an add-on treatment. Cochrane criteria were followed.

Results: Thirteen studies encompassing 872 participants underwent analysis. Both pairwise and network meta-analysis indicated that acupuncture, psychotherapy, and antidepressants were comparable in clinical efficacy rate and in reducing Hamilton Depression Scale and Edinburgh Postnatal Depression Scale scores. Acupuncture and psychotherapy also effectively mitigated concurrent anxiety symptoms. Combining acupuncture with antidepressants augmented therapeutic efficacy and reduced reported gastrointestinal adverse effects associated with antidepressant use. Acupuncture combined with psychotherapy offered similar benefits with superior safety profile. However, the quality of evidence ranged from very low to low due to significant risks of bias and limited sample sizes. The efficacy of psychotherapy and the combination of acupuncture and psychotherapy might be underestimated, as most RCTs used supportive therapy or individual counseling as positive controls instead of recommended approaches like interpersonal psychotherapy (IPT) or cognitive behavioral therapy (CBT) per PPD guidelines.

Conclusion: Current evidence precludes strong recommendations of administering acupuncture in PPD. Rigorous RCTs are essential to validate promising outcomes observed in comparisons between acupuncture, antidepressants, and their combined application. It remains inconclusive whether acupuncture's antidepressive effect is specific or non-specific. Given that psychotherapy is a recommended first-line treatment, investigating the potential efficacy enhancement of combining acupuncture with IPT/CBT is paramount to ascertain the preferred therapeutic approach for PPD.

Keywords: acupuncture; antidepressants; clinical trials; cognitive behavioral therapy; interpersonal psychotherapy; postpartum depression.

Figure 1

Flow Diagram of the Study Selection.

Figure 2

The Risk of Methodological Bias in the Included Studies. (A) Risk of Bias summary for RCTs (B) Risk of Bias graph for RCTs.

Figure 3

Cumulative Ranking Plots. (A) to (H) demonstate the primary outcome measures included in the quantitative analysis. (A) shows the clinical efficacy rate; (B) shows HAM-D scores; (C) shows EPDS scores; (D) shows SDS scores; (E) shows SAS scores; (F) shows serum serotonin levels; (G) shows serum estradiol levels; (H) shows serum orphanin-FQ levels.

Figure 4

League Table. (A) to (H) demonstate the primary outcome measures included in the quantitative analysis. (A) shows the clinical efficacy rate; (B) shows HAM-D scores; (C) shows EPDS scores; (D) shows SDS scores; (E) shows SAS scores; (F) shows serum serotonin levels; (G) shows serum estradiol levels; (H) shows serum orphanin-FQ levels.