Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial

Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people, especially war veterans, with a prevalence reaching 30% in certain populations. Although effective treatments such as psychotherapy and pharmacotherapy exist, their effectiveness is limited by adverse effects and high dropout rates. Acupuncture has emerged as a promising intervention, with positive preliminary data for PTSD. This randomized controlled trial was conducted at the Tibor Rubin VA Medical Center in California from April 2018 to May 2022, with the goal of comparing verum acupuncture with sham acupuncture (minimal needling) on clinical and physiologic outcomes.

The study design was a two-arm, parallel, prospective, blinded randomized controlled trial hypothesizing the superiority of verum acupuncture over sham. Ninety-three combat veterans seeking treatment for PTSD were included, aged 18 to 55 years, diagnosed with PTSD by DSM-5 criteria and with a CAPS-5 score ≥ 26. The traumatic event criterion required that it occur during a combat mission. The interventions consisted of 1-hour sessions twice weekly, with 15 weeks to complete up to 24 sessions.

Verum acupuncture included intake interview, pulse and tongue observation, standard needling to obtain deqi, needle retention for 30 minutes, and electrical stimulation. The protocol used standardized points developed in prior work, alternating between supine (11 points) and prone (14 points) positions. Sham acupuncture used three elements: location 2 cm lateral or medial to the reference points, superficial insertion (< 0.25 inch), and relative absence of stimulation owing to shallow insertion and the use of a sham electrostimulator. The primary outcome was the change in PTSD symptom severity measured by the CAPS-5 scale.

The secondary outcome was the change in fear-potentiated startle response during fear-conditioning extinction. The results showed that 85 men and 8 women (mean age 39.2 years) were randomized. In intention-to-treat analysis, there was a large treatment effect of verum acupuncture (Cohen d = 1.17), a moderate effect of sham (d = 0.67), and a moderate between-group effect favoring verum acupuncture (mean difference 7.1 points; p = 0.005). The pattern of effect was similar in the per-protocol analysis: verum acupuncture d = 1.53; sham d = 0.86; between-group difference 7.4 points (p = 0.01).

There was a significant reduction in fear-potentiated startle during extinction in the verum acupuncture group, but not in the sham group, and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Dropout rates were low and there were no serious adverse events. Strengths of the study include the superiority design using sham to assess non-specific effects, a standardized acupuncture protocol with elective preselected points, and psychophysiologic assessment showing a biologic effect. Limitations include the inability to fully blind the acupuncturists, the absence of an inert placebo, the specific population of combat veterans with exclusion criteria, and the lack of a follow-up period to assess durability of effects.

This study represents a significant advance in the evidence for acupuncture in PTSD, demonstrating clinical efficacy and favorable effects on the psychobiology of PTSD in combat veterans.