Acupuncture for treatment of anxiety, an overview of systematic reviews

doi:10.1016/j.ctim.2019.02.013

Complementary Therapies in Medicine

Volume 43, April 2019, Pages 247-252

https://doi.org/10.1016/j.ctim.2019.02.013 Get rights and content

Highlights

•
We aimed to evaluate the methodological quality and summarize evidence of important outcomes of systematic reviews (SRs)/Meta analyses (MAs) of acupuncture for anxiety.
•
We conducted a comprehensive literature search for SRs/MAs in six databases, AMSTAR-2 was used to assess the methodological quality of the reviews, and GRADE was used to rate the quality of evidence.
•
Although most of the included reviews indicated that acupuncture group was more effective than control group in the treatment of anxiety, the methodological quality of the included reviews and the quality of evidence were low.

Abstract

Purpose

To evaluate the methodological quality and summarize evidence of important outcomes of systematic reviews (SRs)/Meta analyses (MAs) of acupuncture for anxiety.

Methods

We conducted a comprehensive literature search for SRs/MAs in PubMed, EMBASE, Cochrane library, Chinese Biomedical Databases (CBM), Wanfang database and China National Knowledge Infrastructure (CNKI) until November 30, 2018. Three reviewers independently extracted data and assessed the methodological quality of the reviews according to the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to rate the quality of evidence. In the pre-experiment, we used the intra-class correlation coefficient (ICC) to assess reviewer agreement, the ICC value for overall score was 0.978.

Results

Ten reviews were included. The assessment results of AMSTAR-2 showed that the methodological quality of all included studies was critically low. The lowest score were item “provide a list of excluded studies and justify the exclusions” and item “report sources of funding for the included studies”, none of studies provided information about the above two items, followed by the “providing a priori design” item with only two (20%) studies conforming to this item. For GRADE, of the 7 outcomes, high quality evidence was provided in only 1 (14.3%), moderate in 2 (28.6.7%), and low in 4 (57.1%).

Conclusion

Although most of the included reviews indicated that acupuncture group was more effective than control group in the treatment of anxiety, more importantly, the methodological quality of the included reviews and the quality of evidence were low. More high-quality evidence is needed to determine whether acupuncture is more effective than other treatments.

Introduction

Anxiety ranks in the top ten causes of disability worldwide and is the most prevalent psychiatric condition in the European Union with over 60 million people being affected by this condition ¹ it has been reported to contribute substantially to the Global Burden of Disease as stated in the 2015 report (GBD 2015).²

Pharmacotherapy and psychotherapy are conventional treatments for anxiety, and pharmacotherapy has always been considered the standard treatment ³ Nonetheless, pharmacotherapy is not free from concern since they can lead to habituation (especially in long-term treatments), and present side effects and drug interactions, among other problems ⁴^,⁵ Therefore, there is a need for more effective, safer interventions for anxiety. This has led to an increase in the attention received by complementary and alternative interventions such as acupuncture, which is the most widely used of such approaches.⁶ Patients benefit from the lack of side effects and relatively low cost involved in acupuncture.⁷

Some randomized clinical trials (RCTs) investigated acupuncture or acupuncture combined other treatments in anxiety and anxiety disorders.8, 9, 10 However, most studies have been small and the overall results have remained mixed or inconclusive. Several systematic reviews (SRs) and meta-analyses (MAs)11, 12, 13 have been conducted to reveal the effectiveness and safety of acupuncture for the treatment of anxiety. This form of evidence is more comparable than individual trial data, as it uses similar outcome measures (pooled effect sizes, such as standardized mean differences or risk ratios), derived from all randomized clinical trials, and can be systematically reviewed for the risk of bias. However, the quality of these SRs and MAs has not been evaluated, which is an indispensable step before treatment recommendations can confidently be made.

The current study aimed to fill these gaps in the literature. We performed an overview of SRs/MAs to (1) evaluate the methodological quality of these SRs/MAs using AMSTAR-2, (2) rate the quality of evidence of important outcomes from included SRs/MAs using the GRADE approach and (3) summarize the conclusions of these SRs/MAs.

Section snippets

Material and methods

The overview was conducted according to the Cochrane handbook.¹⁴ Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as well as some high quality methodological articles.¹⁵^,¹⁶

Study selection

The literature search yielded 252 reports, of which 41 were excluded because of duplication, and 182 were excluded on the basis of title or abstract that was irrelevant to the topic, and 19 were excluded from the remaining 29 articles after reading the full text. Therefore, 10 SRs/Mas¹¹^,21, 22, 23, 24, 25, 26, 27, 28, 29 were included in this overview. The PRISMA flow chart of literature studies for SRs/MAs is illustrated in Fig. 1.

Characteristics of included studies

The characteristics of the included reviews are summarized in

Discussion

The number of SRs/MAs of acupuncture for anxiety is increasing annually. The purpose of this overview was to evaluate the methodological quality and quality of evidence from published SRs/MAs and to provide an evidence-based assessment and an objective summary on the effectiveness of acupuncture for anxiety.

To our knowledge, this overview of meta-analyses is the first one to systematically evaluate the SRs/MAs of acupuncture treatment of anxiety. Our overview included 10 SRs/MAs, published in

Strengths and limitations

This overview is the first study to assess the methodological quality of SRs/MAs using the AMSTAR and GRADE approach to evaluate the quality of evidence for the efficacy of acupuncture in anxiety patients, and in order to ensure the reliability of our evaluation results, we used ICC to assess reviewer agreement.

However, our study has some limitations. First, we did not re-extract data from original research, although this was outside the scope of our review, which aimed to describe available

Conclusion

Most of the included reviews suggested that the acupuncture group was more effective than traditional medicine and sham acupuncture in the treatment of anxiety, nevertheless, the results of this study showed that the methodological quality of most of the included reviews and the quality of evidence were low, more high-quality randomized trials and MAs are needed to determine whether acupuncture is more effective than other treatments.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

Supported by the Fundamental Research Funds for the Central Universities (16LZUJBWTD013, 18LZUJBWZX006): Evidence - based sociology research.

References (35)

D. Amorim et al.
Acupuncture and electroacupuncture for anxiety disorders: A systematic review of the clinical research
Complement Ther Clin Pract
(2018)
L. Li et al.
Network meta-analyses could be improved by searching more sources and by involving a librarian
J Clin Epidemiol
(2014)
G.H. Guyatt et al.
GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology
J Clin Epidemiol
(2011)
F.K. Allan et al.
Acupuncture for anxiety in dental patients: Systematic review and meta-analysis
Eur J Integr Med
(2018)
J. Tian et al.
The methodological and reporting quality of systematic reviews from China and the USA are similar
J Clin Epidemiol
(2017)
L. Yao et al.
The quality of evidence in Chinese meta-analyses needs to be improved
J Clin Epidemiol
(2016)
R.E. Schmieder et al.
Scientific data and transparency of conflict of interest are important, not biased editorial without facts
JACC Cardiovasc Interv
(2016)
L. Mcauley et al.
Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses?
Lancet
(2000)
O. Remes et al.
A systematic review of reviews on the prevalence of anxiety disorders in adult populations
Brain Behav
(2016)
V.L. Feigin et al.
Global, regional, and national burden of neurological disorders during 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015
Lancet Neurol
(2017)

B. Bandelow et al.

Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care

Int J Psychiatry Clin Pract

(2012)

S.L. Goyatá et al.

Effects from acupuncture in treating anxiety: integrative review

Revista Brasileira de Enfermagem.

(2016)

L. Arranz et al.

Effect of acupuncture treatment on the immune function impairment found in anxious women

Am J Chin Med (Gard City N Y)

(2007)

C. Zollman et al.

ABC of complementary medicine. Complementary medicine in conventional practice

Br Med J

(1999)

K. Matthias et al.

Auricular acupuncture for dental anxiety: a randomized controlled trial

Anesth Analg

(2007)

A. Paraskeva et al.

Needling of the extra 1 point decreases BIS values and preoperative anxiety

Am. J. Chin. Med.

(2004)

S. Zarei et al.

Acupuncture decreases competitive anxiety prior to a competition in young athletes: A randomized controlled trial pilot study

J Complement Integr Med

(2017)

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Acupuncture for the relief of chronic pain: Regulating negative emotions and reward/motivation circuits based on the theory of “spirit-regulation with acupuncture”<sup>☆</sup> 针灸改善慢性疼痛的新视角:“针灸治神”调控负性情绪及奖赏/动机环路
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Chronic pain is often accompanied by negative emotions, and the progression of negative emotions may further impede pain relief. Both chronic pain and negative emotions are closely associated with reward/motivation circuits. Treatment with acupuncture is effective for the relief of pain and emotional disorders, although the acupoint combinations vary. Thus, this study aimed to elucidate the relationship of chronic pain and emotional disorders with the reward/motivation circuits. In association with the theory on “seven emotional factors that cause pain” in traditional Chinese medicine, the potential effect mechanism of “spirit-regulation with acupuncture” for the relief of chronic pain and negative emotions was explored. The findings suggest that chronic pain and its related negative emotions may be effectively relieved with acupuncture after optimizing its acupoint combination based on “spirit-regulation”. However, the role of reward/motivation circuits for negative emotions in the relief of chronic pain with acupuncture needs to be demonstrated.
Acupuncture in hematologic malignancies and hematopoietic cell transplantation
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Although the exact mechanism of acupuncture is still not fully understood, research suggests that some of the effects are mediated via modulation of the nervous system [4–6]. Acupuncture has been used in managing various symptoms and diseases such as anxiety, depression, low back pain, inflammatory bowel disease, and cancer symptoms [7–13]. Cancer survivors are more likely to use acupuncture for symptom management (10%) when compared to non-cancer controls (6%) [14].
Acupuncture is an integrative medicine modality that has been used historically and studied recently for managing various symptoms and diseases. Patients with hematological malignancies often experience a high symptom burden including pain, fatigue, nausea, vomiting, and insomnia. Pharmacological interventions are the mainstay of managing these symptoms, although they may not provide adequate control or are not well tolerated due to side effects. There have been many randomized controlled trials of acupuncture on reduction of these symptoms. In this review, we will summarize the current evidence on the effect of acupuncture on the management of common symptoms experienced by patients with hematological malignancies and the current understanding of acupuncture's mechanism of action. The evidence is the strongest for reducing pain and nausea vomiting, less strong for symptoms such as peripheral neuropathy, fatigue, constipation, insomnia, night sweat, and pruritus.
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However, these drugs can cause habituation, serious adverse effects and drug interactions.10 In this context, we hypothesized that the anxiolytic effect of AC11 can increase the formation of self-efficacy beliefs and, consequently, increase the academic performance. One great advantage of AC on conventional treatments is that AC does not cause side effects in the vast majority of patients.12
Pre-exam anxiety is highly prevalent among students of all educational levels, leading to decreased performance. This anxiety causes psychological and physiological changes related to stress, which can affect the formation of self-efficacy beliefs. Studies have shown a correlation between pre-exam anxiety, self-efficacy and academic performance. Acupuncture (AC) has an anxiolytic effect recognized in the treatment of generalized anxiety disorder and anxiety in the pre-operative and pre-exam period. Stress-related variables such as cortisol level, blood pressure and heart rate can be modulated by AC. Brain regions related to the control of the autonomic nervous system, emotional, memory and cognitive processing are also modulated by AC. Therefore, the aim of this study is present a hypothesis about how the AC reduces anxiety and stress through neuroendocrine modulation, optimizing the formation of self-efficacy beliefs, which promote behaviors responsible for improved performance.
La ansiedad previa a los exámenes es muy frecuente entre los estudiantes de todos los niveles educativos, lo que lleva a una disminución del rendimiento. Esta ansiedad provoca cambios psicológicos y fisiológicos relacionados con el estrés, que pueden afectar la formación de creencias de autoeficacia. Los estudios han demostrado una correlación entre la ansiedad previa al examen, la autoeficacia y el rendimiento académico. La acupuntura (AC) tiene un efecto ansiolítico reconocido en el tratamiento del trastorno de ansiedad generalizada y la ansiedad en el período preoperatorio y preexamen. Las variables relacionadas con el estrés, como el nivel de cortisol, la presión arterial y la frecuencia cardíaca, pueden ser moduladas por AC. Las regiones cerebrales relacionadas con el control del sistema nervioso autónomo, emocional, memoria y procesamiento cognitivo también son moduladas por AC. Por lo tanto, el objetivo de este estudio es presentar una hipótesis acerca de cómo la AC reduce la ansiedad y el estrés a través de la modulación neuroendocrina, optimizando la formación de creencias de autoeficacia, lo que promueve comportamientos responsables para mejorar el rendimiento.
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In a review investigating acupuncture therapy for people with anxiety disorders who were not undergoing IVF, decreases in anxiety were consistently reported across 13 studies (Amorim et al., 2018). However, the quality of evidence was considered low, primarily due to inadequate blinding (Li et al., 2019), small studies and heterogeneity of anxiety measures (Pilkington, 2010). In patients undergoing IVF, acupuncture was superior to control treatment and provided moderate benefit for IVF-related state anxiety (number of studies [n] = 5, number of participants [N] = 988, standardized mean difference [SMD] 0.48, 95% confidence interval [CI] 0.04–0.92, P = 0.03, I2 = 90%) (Chu et al., 2017).
Patients undergoing IVF experience high levels of IVF-related state anxiety. Non-pharmacological interventions such as acupuncture may provide support, but its effect on IVF-related anxiety is unclear. This was a systematic review and meta-analysis to examine the effect of acupuncture on IVF-related state anxiety. The primary outcome was state anxiety after embryo transfer or oocyte retrieval as assessed by the State-Trait Anxiety Inventory, Hamilton Anxiety Scale, visual analogue scale or Standard Form 36. Eight trials with 2253 participants were reviewed, and 1785 participants completed an anxiety assessment. Using the random effects model, the meta-analysis found small but significant effects on state anxiety with acupuncture versus any control (standardized mean difference –0.21, 95% confidence interval –0.39 to –0.04, representing very low certainty evidence). Evidence was limited by the moderate number of included studies of an intermediate median sample size (n = 191). There was also a high risk of performance bias and substantial heterogeneity across trials. Acupuncture is a drug-free and safe treatment that may benefit those who are burdened with IVF-related anxiety, but more investigation is needed for confirmation.

View all citing articles on Scopus

¹: Meixuan Li and Xin Xing are Co-first authors.

View full text

Acupuncture for treatment of anxiety, an overview of systematic reviews

Highlights

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Study selection

Characteristics of included studies

Discussion

Strengths and limitations

Conclusion

Conflict of interest

Funding

Complement Ther Clin Pract

J Clin Epidemiol

J Clin Epidemiol

Eur J Integr Med

J Clin Epidemiol

J Clin Epidemiol

JACC Cardiovasc Interv

Lancet

A systematic review of reviews on the prevalence of anxiety disorders in adult populations

Brain Behav

Global, regional, and national burden of neurological disorders during 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015

Lancet Neurol

Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care

Int J Psychiatry Clin Pract

Effects from acupuncture in treating anxiety: integrative review

Revista Brasileira de Enfermagem.

Effect of acupuncture treatment on the immune function impairment found in anxious women

Am J Chin Med (Gard City N Y)

ABC of complementary medicine. Complementary medicine in conventional practice

Br Med J

Auricular acupuncture for dental anxiety: a randomized controlled trial

Anesth Analg

Needling of the extra 1 point decreases BIS values and preoperative anxiety

Am. J. Chin. Med.

Acupuncture decreases competitive anxiety prior to a competition in young athletes: A randomized controlled trial pilot study

J Complement Integr Med