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Acupuncture for Depression? : A Systematic Review of Systematic

Reviews
E. Ernst, Myeong Soo Lee and Tae-Young Choi
Eval Health Prof 2011 34: 403 originally published online 7 December 2010
DOI: 10.1177/0163278710386109

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 Evaluation & the Health Professions
34(4) 403-412
The Author(s) 2011
Acupuncture for Reprints and permission:
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Depression?: A DOI: 10.1177/0163278710386109
http://ehp.sagepub.com

Systematic Review
of Systematic Reviews

E. Ernst1, Myeong Soo Lee1,2, and Tae-Young Choi2

Abstract
Acupuncture is often advocated as a treatment for depression, and several
trials have tested its effectiveness. Their results are contradictory and even
systematic reviews of these data do not arrive at uniform conclusions. The
aim of this review is to critically evaluate all systematic reviews of the
subject with a view of assisting clinical decisions. Thirteen electronic
databases were searched to identify all relevant articles. Data of these
systematic reviews and the primary studies they included were extracted
independently by the two authors according to predefined criteria. Eight
systematic reviews including seventy-one primary studies were found. Five
of the reviews arrived at positive conclusions and three did not. All the
positive reviews and most of the positive primary studies originated from
China. There are reasons to believe that these reviews are less than reliable.
In conclusion, the effectiveness of acupuncture as a treatment of depression
remains unproven and the authors findings are consistent with acupuncture
effects in depression being indistinguishable from placebo effects.

1
Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK
2
Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, South Korea

Corresponding Author:
E. Ernst, Complementary Medicine, Peninsula Medical School, University of Exeter, 25 Victoria
Park Road, Exeter EX2 4NT, UK
Email: Edzard.Ernst@pms.ac.uk

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404 Evaluation & the Health Professions 34(4)

Keywords
depression, acupuncture, alternative medicine, bias, evidence

Acupuncture has been proposed as a nondrug therapy for depression, but

skeptics are keen to point out that acupuncture lacks biological plausibility.
Several trials, some of reasonably good quality, have tested the hypothesis
that acupuncture alleviates the symptoms of depression (Ernst, Rand, &
Stevinson, 1998). However, these data are highly contradictory and there-
fore they have the potential to confuse clinicians.
In this situation, a systematic review might create clarity. In recent years,
several systematic reviews of acupuncture for depression have emerged.
Confusingly, they also arrive at dramatically different conclusions. Conse-
quently, the existing systematic reviews are not a useful tool for assisting
clinical decisions either.
This article is aimed at summarizing the existing systematic reviews and
at clarifying why their conclusions are contradictory. Our objective is to
provide clinicians with the most reliable evidence about the therapeutic
value of acupuncture in the management of depression.

Method
Electronic literature searches were conducted in Medline, Embase, Amed,
CINAHL, Health Technology Assessments, DARE, the Cochrane Library,
five Korean medical database (Korean Studies Information, DBPIA, Korea
Institute of Science and Technology Information, KoreaMed, and Research
Information Service System), and one Chinese database (CNKI) without
restrictions of time or language. In addition, our departmental files were
hand searched. The search terms were acupuncture, depression, systematic
review, and meta-analysis. Abstracts of reviews thus located were inspected
by two authors and those appearing meet the inclusion criteria were
retrieved and read in full by two authors. Reviews were defined as systema-
tic if they included an explicit and repeatable method for searching the
scientific literature and if there were explicit and repeatable inclusion and
exclusion criteria for studies.
To be included, systematic reviews had to be concerned specifically
with the effectiveness of acupuncture for depression and to include evi-
dence from at least two controlled clinical trials. Systematic reviews were
considered, regardless of the acupuncture types including body, ear or elec-
tro acupuncture, and so on. Systematic reviews of complex packages of
intervention that happened to include acupuncture as one of several

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Ernst et al. 405

elements were excluded. Reviews that depended on previous systematic

reviews for their primary data were also excluded. All primary studies
included in these systematic reviews were identified and key data were
extracted from these trials. Data were extracted independently by two
authors (EE and MSL) using predefined criteria (Tables 1 and 2). Disagree-
ments were resolved by discussion between the authors.
Judgments about the quality of the primary studies were taken from the
respective systematic reviews. The Overview Quality Assessment Ques-
tionnaire (OQAQ) was used to evaluate the methodological quality of all
included systematic reviews (Oxman & Guyat, 1991). The score ranges
from 1 to 7; a score of 3 or less was considered as indicative of extensive
or major flaws and a score of 5 or more as suggesting minor or minimal
flaws. The two authors assessed the OQAQ independently and discrepan-
cies were settled by discussion.

Results
Eight systematic reviews were found (Leo & Ligot, 2007; Mukaino, Park,
White, & Ernst, 2005; Smith, Hay, & MacPherson, 2010; Sun, Chen, Gao,
Xiong, 2008; Wang, Sun, Zou, & Zhang, 2008; Wang, Qi, et al., 2008;
Xiong et al., 2009; Zhang, Chen, Yip, Ng, & Wong, 2010; Zhong, Huang,
& Li, 2008). Key data are summarized in Table 1. Six reviews (Sun et al.,
2008; Wang, Sun, et al., 2008; Wang, Qi, et al., 2008; Xiong et al., 2009;
Zhang et al., 2010; Zhong et al., 2008) originated from China, one from the
United States (Leo & Ligot, 2007), and two were multinational efforts
(Mukaino et al., 2005; Smith et al., 2010). All of the Chinese reviews (Sun
et al., 2008; Wang, Sun, et al., 2008; Wang, Qi, et al., 2008; Xiong et al.,
2009; Zhang et al., 2010; Zhong et al., 2008) arrived at positive conclusions,
while all of the non-Chinese reviews failed to do so (Leo & Ligot, 2007;
Mukaino et al., 2005; Smith et al., 2010). The reviews included between
7 and 30 randomized controlled trials (RCTs), and there was considerable
overlap regarding the primary studies. In total, the reviews included 71 dif-
ferent primary studies (Table 2).
Four reviews (Sun et al., 2008; Wang, Sun, et al., 2008; Xiong et al.,
2009; Zhang et al., 2010) included exclusively or mostly Chinese studies,
and all of these reviews reached positive conclusions about the effective-
ness of acupuncture. Three of the Chinese reviews failed to include any of
the RCTs that originated from outside China (Sun et al., 2008; Wang, Sun,
et al., 2008; Xiong et al., 2009). The six positive (Sun et al., 2008; Wang,
Sun, et al., 2008; Wang, Qi, et al., 2008; Xiong et al., 2009; Zhang et al.,

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 Table 1. Key Data From Systematic Reviews

406
Quality of Results of
Primary Studies Primary Studies
Number of Primary (Number of (Number of
First Author RCTs (Country of Study-High/mod- StudyPositive/ Quality of
(Year) Origin of Total erate/poor Neutral/ Overall Conclusion Reviewb
Country Primary Studies) Sample Size quality)a Negative) (Quote) Meta-Analysis (OQAQ) Comment

Smith (2010) 30 (China: 24; USA: 2,812 4/9/17 21/7/2 . . . insufficient Several meta-analyses 7 Cochrane review.
Australia 2; Germany: evidence to were performed for Superiority of
and UK 2; Australia: recommend the different types of acupuncture
1; UK: 1) use of controls. The results compared to
acupuncture for show no significant waiting list could
people with differences between be due to
depression acupuncture and drug nonspecific
treatments or sham effects of
acupuncture. acupuncture.
Zhang (2009) 35 (China: 33; USA:1; 3,678 6/23/6 17/15/3 Acupuncture therapy RR 1.06 (95% 7 Discrepancy
China Germany: 1) is safe and CI [0.97, 1.17]) between
effective in compared with meta-analytic
treating major antidepressants result and
depressive conclusion
disorder
Xiong (2009) 9 (China:9) 903 0/2/7 5/2/2 Acupuncture is not Several meta-analyses 7 The conclusion

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China inferior to were performed for regarding
western medicine different types of non-inferiority
and it is worth controls. The results was not based on
noting that show no significant adequately
acupuncture is differences between designed
associated with acupuncture and non-inferiority
few adverse conventional drug studies.
reactions therapy.

(continued)
 Table 1 (continued)
Quality of Results of
Primary Studies Primary Studies
Number of Primary (Number of (Number of
First Author RCTs (Country of Study-High/mod- StudyPositive/ Quality of
(Year) Origin of Total erate/poor Neutral/ Overall Conclusion Reviewb
Country Primary Studies) Sample Size quality)a Negative) (Quote) Meta-Analysis (OQAQ) Comment

Wang (2008a) 8 (China: 2; USA:3; 477 4/3/1 7/0/1 . . . acupuncture was SMD 0.65 (95% CI 6 Positive effect for
China Germany: 2; an effective [1.18, 0.11]) improvement of
Australia:1) treatment that compared with sham depression but
could significantly acupuncture not for response
reduce the rate
severity of disease
in patients with
depression
Zhong (2008) 7 (China: 4; USA: 2; 895 5/1/1 4/0/3 Based on current WMD 0.87 (95% CI 6 Cochrane review
China Australia: 1) evidence, [2.08, 0.35])
acupuncture is a compared with
promising western drugs
treatment for
depression
Wang (2008b) 14 (China: 14) 1,317 1/3/10 5/5/4 Both acupuncture WMD 0.93 (95% CI 6 Discrepancy

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China and medication [1.48, 0.38]) between
possibly are compared with meta-analytic
effective for western drug result and HAMD
depression with OR 0.73 (95% scores
good safety CI [0.38, 1.40])
compared with
western drugs

(continued)

407
 408
Table 1 (continued)
Quality of Results of
Primary Studies Primary Studies
Number of Primary (Number of (Number of
First Author RCTs (Country of Study-High/mod- StudyPositive/ Quality of
(Year) Origin of Total erate/poor Neutral/ Overall Conclusion Reviewb
Country Primary Studies) Sample Size quality)a Negative) (Quote) Meta-Analysis (OQAQ) Comment

Sun (2008) China 8 (China:8) 619 1/3/4 3/4/1 Acupuncture is not Several meta-analyses 6 Only Chinese studies
inferior to were performed for were included
western medicine each drug. The results
and it is worth show no significant
noting that differences between
acupuncture is acupuncture and
associated with conventional
few adverse antidepressants
reactions
Leo (2007) US 9 (China: 5; USA: 2; 9 74 1/2/6 5/4/0 . . . the evidence No 5 Jadad scores of some
Germany: 2) thus far is primary studies
inconclusive differed from
those of Wang
Mukaino (2005) 7 (China: 4; USA: 1; 509 1/1/5 4/3/0 The evidence from No 6 The first authors
Japan, US; UK Germany: 2) controlled trials is own review

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insufficient . . .

Note. RCT randomized controlled trials; SMD Standardized Mean Difference; WMD Weight Mean Difference.
a
Quality of primary studies was scored by Jadad score. Jadad score  4: having high quality; Jadad score 3: having moderate quality; Jadad score  2: having low
quality.
b
OQAQ Overview Quality Assessment Questionnaire. The overall score is from 1 to 7. OQAQ  3: having extensive or major flaws; 5  OQAQ: having minor
or minimal flaws.
Ernst et al. 409

2010; Zhong et al., 2008) and one of the negative reviews (Smith et al.,
2010) used a meta-analytical approach. Most of the reviews seemed
to be of reasonably good technical quality. There was considerable
overlap between the systematic reviews in relation to the primary data
included.
Seventy one primary studies were included across the reviews. They
tested acupuncture versus sham acupuncture (n 12), acupuncture versus
drugs (n 54), and acupuncture versus waiting list or no treatment (n 5).
Thirty-seven of these studies reported positive effects of acupuncture and
twenty-five reported effects equivalent to those of drug treatments, while
nine trials were negative. The quality of primary studies was high in 9 trials,
moderate in 34 studies, and low in 28 trials. Most studies of them were con-
ducted in China, three in the United States, two in Germany, and one each in
Australia and the United Kingdom. Of the 64 primary studies originating
from China, only 6 reported a negative result.

Discussion
Our analysis shows that a surprisingly high number of systematic reviews of
acupuncture for depression have been published. Their conclusions about
the therapeutic value of acupuncture for depression differ considerably.
These discrepancies require an explanation.
One reason could be that the totality of the data gradually became more
and more positive as more RCTs were published. Yet, Table 1 shows that
neither the number of primary studies nor the total sample size of the sys-
tematic reviews increased in a linear fashion. Furthermore, there is no clear
trend to suggest that the primary studies became more and more positive
over time (data not shown). What is striking, however, is that those sys-
tematic reviews arriving at positive conclusions (Sun et al., 2008; Wang,
Sun, et al., 2008; Wang, Qi, et al., 2008; Xiong et al., 2009; Zhang et al.,
2010; Zhong et al., 2008) all originated from China and, with the exception
of one (Wang, Qi, et al., 2008), they all relied heavily on primary studies
from China. Crucially, these reviews also tended to exclude non-Chinese
RCTs: in 2007, at least four non-Chinese RCTs were available (Leo &
Ligot, 2007), yet these studies were excluded from the systematic reviews
that most heavily relied on Chinese studies (Sun et al., 2008; Wang, Sun,
et al., 2008; Zhang et al., 2010).
Vickers et al. were the first who pointed out that virtually 100% of all
acupuncture trials originating from China are positive, that is, suggest
that acupuncture is effective (Vickers, Goyal, Harland, & Rees, 1998). This

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410 Evaluation & the Health Professions 34(4)

Table 2. Information of the Primary Studies

Direction
of Results Design

AT Versus
Number of No-Treatment
Primary AT or Wait-List;
Studies (Total AT Versus Versus AT B
Number 71) +  Sham AT Drug Versus B

Quality of studya
High 9 6 1 2 5 2 2
Moderate 34 18 13 3 4 27 3
Low 28 13 11 4 3 25 0
Origin of study
China 64 31 24 6 5 52 5
United States 3 3 0 0 3 0 0
Germany 2 2 0 0 2 0 0
United Kingdom 1 0 0 1 1 0 0
Design
AT versus sham AT 12 7 2 3
AT versus drug 52 27 21 4
AT versus no- 5 3 2 0
treatment or
wait-list; ATB
versus B

Note. AT acupuncture; clearly positive;  clearly negative; + equivocal.

a
Based on Jadad score. High means 4, moderate 3, and low  2.

finding was later confirmed by other researchers (Tang, Zhan, & Ernst,
1999). The current analysis suggests a similar phenomenon: of the 64 pri-
mary studies from China, only 6 were negative. Our analysis suggests that
also systematic reviews originating from China are far more likely to be
positive than reviews from other countries. In principle, the discrepancy
between results from China and elsewhere could be due to false negative
results of research originating from outside China. Much more likely, how-
ever, it is due to false positive results of research from China. As far as we
know, the reason for this phenomenon is unknown. It casts serious doubts
about the reliability of Chinese acupuncture trials and could provide the key
to understanding the discrepancies in the reviews evaluated here: if a sys-
tematic review includes numerous false positive primary studies, its overall
conclusion is likely to be false positive as well.
We might therefore be faced with a conundrum. On one hand, not con-
sidering acupuncture trials or reviews from China (where acupuncture is

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Ernst et al. 411

practiced more frequently than elsewhere) could mean neglecting crucial

information. On the other hand, including them might risk generating a
misleading impression about the therapeutic value of acupuncture.
It would seem prudent to rely on those systematic reviews that include all
available data are critical in their evaluations and cautious in their
conclusions (Leo & Ligot, 2007; Mukaino et al., 2005; Smith et al.,
2010). In essence, this means that, based on such systematic reviews, the
evidence is consistent with acupuncture effects in depression being indistin-
guishable from placebo effects.

Declaration of Conflicting Interests

The author(s) declared no conflicts of interest with respect to the authorship and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research
and/or authorship of this article: MSL and TY Choi were funded by KIOM
(K10251).

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