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

This systematic review and network meta-analysis represents the most comprehensive study to date on the efficacy of acupuncture in the treatment of post-stroke depression (PSD). Depression affects 30–33% of stroke survivors and significantly impacts functional recovery and quality of life. The researchers conducted a systematic search across six databases and three clinical registry platforms from inception to March 2023, including randomized controlled trials comparing needle-based acupuncture with pharmacotherapy, other non-pharmacologic therapies, or control groups. The methodology was rigorous, following the PRISMA guidelines for network meta-analyses, with risk-of-bias assessment using the revised ROB 2 tool and quality of acupuncture procedures evaluated by the STRICTA instrument.

Sixty-two studies involving 5,308 participants were included, all conducted in China between 2003 and 2022. The analysis included 12 different interventions: acupuncture alone, acupuncture combined with repetitive transcranial magnetic stimulation (rTMS), traditional Chinese medicine (TCM), Western medicine, tai chi, cognitive therapy, psychotherapy, moxibustion, and several combinations of these modalities. The primary outcome was efficacy for PSD as assessed by depressive symptom scales, primarily the Hamilton Depression Rating Scale (HAMD). The results of the network meta-analysis revealed that, compared with Western medicine alone, acupuncture combined with rTMS was superior in reducing depressive symptoms (mean difference: −8.73; 95% CI: −16.64, −0.79).

Similar results were found when comparing acupuncture with TCM and Western medicine, acupuncture with TCM, TCM alone, acupuncture with Western medicine, and acupuncture alone. Compared with usual care, acupuncture alone or in combination with other interventions significantly reduced HAMD scores. The ranking analysis using SUCRA (Surface Under the Cumulative Ranking) showed that acupuncture combined with rTMS had the highest probability (49.4%) of being the most effective treatment for improving depressive symptoms. The next best options were acupuncture with TCM and Western medicine (11.1%), acupuncture with TCM (10.6%), and acupuncture with tai chi (10.3%).

The pairwise meta-analysis of ten studies using the Modified Edinburgh-Scandinavian Stroke Scale (MESSS) demonstrated that acupuncture was significantly associated with better neurologic function recovery compared with usual care or Western medicine. The most frequently used acupuncture points included Bai-Hui, Shen-Ting, and Nei-Guan, reflecting a traditional approach focused on calming the mind and regulating qi. Quality assessment of the studies revealed important limitations: only six studies (10%) were rated as low risk of bias, 27 (44%) as some concerns, and 26 (42%) as high risk of bias. The STRICTA assessment showed inadequate reporting of several aspects of acupuncture procedures, with no study adequately describing the treatment context or rationale for controls.

Heterogeneity was substantial (I² = 97.4%), reflecting variations in acupuncture protocols, treatment durations, and study populations. The inconsistency analysis using node-splitting showed no significant inconsistencies between direct and indirect evidence. The clinical implications are substantial, suggesting that combined therapies, particularly acupuncture with rTMS, may offer benefits superior to isolated conventional treatments for PSD. This is clinically relevant given that selective serotonin reuptake inhibitors, the current first-line treatment, can increase the risk of intracerebral hemorrhage.

Acupuncture offers a minimally invasive alternative with a favorable safety profile.