12
Acupuncture for schizophrenia: a systematic review and meta-analysis M. S. Lee, 1,2 B.-C. Shin, 3 P. Ronan, 4 E. Ernst 2 Introduction Schizophrenia is a mental illness that is among the world’s ten most important causes of long-term dis- ability (1). Antipsychotic medications are the main- stay for managing schizophrenia. The adverse events associated with such treatments lead patients to seek complementary and alternative medicine (CAM), usually as adjuncts to conventional medicine (2,3). The main motivation for using CAM is the hope for improvements in mood and alleviation of psychiatric symptoms (4). In many countries, the social circum- stances of people with schizophrenia limit their abil- ity to access CAM (5). Acupuncture is one of the most popular types of CAM. It is sometimes used as a treatment for schizo- phrenia (3) and claimed to be effective in improving mood including anxiety and depression (4,6,7). Con- sidering these facts, it is pertinent to investigate the effectiveness of acupuncture for treating schizophre- nia. Currently, two reviews of this subject are available (8,9). Unfortunately, they included only publications published before 2001 and are now out of date. The objective of this systematic review was to summarise and critically assess the evidence from randomised clinical trials (RCTs) for or against the effectiveness of acupuncture in treating schizophre- nia. SUMMARY Background: Acupuncture is one of the most popular types of complemen- tary alternative medicine. It is sometimes used as a treatment for schizophrenia. Aims: The objective of this review is to assess systematically the clinical evidence for or against acupuncture as a treatment for schizophrenia. Methods: We searched 20 databases from their inception to May 2009 without language restric- tions. All randomised clinical trials (RCTs) of acupuncture, with or without electrical stimulation or moxibustion for patients with schizophrenia were considered for inclusion. Results: Thirteen RCTs, all originating from China, met the inclusion cri- teria. One RCT reported significant effects of electroacupuncture (EA) plus drug therapy for improving auditory hallucunations and positive symptom compared with sham EA plus drug therapy. Four RCTs showed significant effects of acupuncture for response rate compared with antipsychotic drugs [n = 360, relative risk (RR): 1.18, 95% confidence interval (CI): 1.03–1.34, p = 0.01; heterogeneity: s 2 = 0.00, v 2 = 2.98, p = 0.39, I 2 = 0%]. Seven RCTs showed significant effects of acupuncture plus antipsychotic drug therapy for response rate compared with antipsychotic drug therapy (n = 457, RR: 1.15, 95% CI: 1.04–1.28, p = 0.008, heterogeneity: s 2 = 0.00, v 2 = 6.56, p = 0.36, I 2 = 9%). Two RCTs tested laser acupuncture against sham laser acupuncture. One RCT found beneficial effects of laser acupuncture on hallucination and the other RCT showed significant effects of laser acupuncture on response rate, Brief Psychiatric Rating Scale and clinical glo- bal index compared with sham laser. The methodological quality was generally poor and there was not a single high quality trial. Conclusion: These results pro- vide limited evidence for the effectiveness of acupuncture in treating the symptoms of schizophrenia. However, the total number of RCTs, the total sample size and the methodological quality were too low to draw firm conclusions. As all studies originated from China, international studies are needed to test whether there is any effect. Review Criteria We included all randomised clinical trials of acupuncture to treat human patients suffering from schizophrenia after searching 20 databases from their inception to May 2009, without language restrictions. Message for the Clinic Acupuncture is one of the most popular types of CAM. It is sometimes used as a treatment for schizophrenia. The results of our systematic review and meta-analysis provided limited evidence for the effectiveness of acupuncture in treating the symptoms of schizophrenia. 1 Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, South Korea 2 Complementary Medicine, Peninsula College of Medicine & Dentistry, Universities of Exeter & Plymouth, Exeter, UK 3 Department of Oriental Rehabilitation Medicine, School of Oriental Medicine, Pusan National University, Yangsan, South Korea 4 Department of Social Work, Community and Mental Health, Canterbury Christ Church University, Kent, UK Correspondence to: Myeong Soo Lee, Division of Standard Research, Korea Institute of Oriental Medicine, 461-24, Jeonmin-dong, Yuseong-gu, Daejeon 305-811, Korea Tel.: + 82 42 868 9266 Fax: + 82 42 863 9464 Email: [email protected]; [email protected] Disclosure None. Linked Comment: Samuels. Int J Clin Pract 2009; 63: 1553–5. META-ANALYSIS ª 2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 1622–1633 1622 doi: 10.1111/j.1742-1241.2009.02167.x

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  • Acupuncture for schizophrenia: a systematicreview and meta-analysis

    M. S. Lee,1,2 B.-C. Shin,3 P. Ronan,4 E. Ernst2

    Introduction

    Schizophrenia is a mental illness that is among the

    worlds ten most important causes of long-term dis-

    ability (1). Antipsychotic medications are the main-

    stay for managing schizophrenia. The adverse events

    associated with such treatments lead patients to seek

    complementary and alternative medicine (CAM),

    usually as adjuncts to conventional medicine (2,3).

    The main motivation for using CAM is the hope for

    improvements in mood and alleviation of psychiatric

    symptoms (4). In many countries, the social circum-

    stances of people with schizophrenia limit their abil-

    ity to access CAM (5).

    Acupuncture is one of the most popular types of

    CAM. It is sometimes used as a treatment for schizo-

    phrenia (3) and claimed to be effective in improving

    mood including anxiety and depression (4,6,7). Con-

    sidering these facts, it is pertinent to investigate the

    effectiveness of acupuncture for treating schizophre-

    nia. Currently, two reviews of this subject are available

    (8,9). Unfortunately, they included only publications

    published before 2001 and are now out of date.

    The objective of this systematic review was to

    summarise and critically assess the evidence from

    randomised clinical trials (RCTs) for or against the

    effectiveness of acupuncture in treating schizophre-

    nia.

    SUMMARY

    Background: Acupuncture is one of the most popular types of complemen-

    tary alternative medicine. It is sometimes used as a treatment for schizophrenia.Aims: The objective of this review is to assess systematically the clinical evidence

    for or against acupuncture as a treatment for schizophrenia. Methods: We

    searched 20 databases from their inception to May 2009 without language restric-

    tions. All randomised clinical trials (RCTs) of acupuncture, with or without electrical

    stimulation or moxibustion for patients with schizophrenia were considered for

    inclusion. Results: Thirteen RCTs, all originating from China, met the inclusion cri-

    teria. One RCT reported significant effects of electroacupuncture (EA) plus drug

    therapy for improving auditory hallucunations and positive symptom compared with

    sham EA plus drug therapy. Four RCTs showed significant effects of acupuncture

    for response rate compared with antipsychotic drugs [n = 360, relative risk (RR):

    1.18, 95% confidence interval (CI): 1.031.34, p = 0.01; heterogeneity:

    s2 = 0.00, v2 = 2.98, p = 0.39, I2 = 0%]. Seven RCTs showed significant effectsof acupuncture plus antipsychotic drug therapy for response rate compared with

    antipsychotic drug therapy (n = 457, RR: 1.15, 95% CI: 1.041.28, p = 0.008,

    heterogeneity: s2 = 0.00, v2 = 6.56, p = 0.36, I2 = 9%). Two RCTs tested laseracupuncture against sham laser acupuncture. One RCT found beneficial effects of

    laser acupuncture on hallucination and the other RCT showed significant effects of

    laser acupuncture on response rate, Brief Psychiatric Rating Scale and clinical glo-

    bal index compared with sham laser. The methodological quality was generally

    poor and there was not a single high quality trial. Conclusion: These results pro-

    vide limited evidence for the effectiveness of acupuncture in treating the symptoms

    of schizophrenia. However, the total number of RCTs, the total sample size and

    the methodological quality were too low to draw firm conclusions. As all studies

    originated from China, international studies are needed to test whether there is

    any effect.

    Review CriteriaWe included all randomised clinical trials of

    acupuncture to treat human patients suffering from

    schizophrenia after searching 20 databases from

    their inception to May 2009, without language

    restrictions.

    Message for the ClinicAcupuncture is one of the most popular types of

    CAM. It is sometimes used as a treatment for

    schizophrenia. The results of our systematic review

    and meta-analysis provided limited evidence for the

    effectiveness of acupuncture in treating the

    symptoms of schizophrenia.

    1Division of Standard Research,

    Korea Institute of Oriental

    Medicine, Daejeon, South Korea2Complementary Medicine,

    Peninsula College of Medicine

    & Dentistry, Universities of

    Exeter & Plymouth, Exeter, UK3Department of Oriental

    Rehabilitation Medicine, School

    of Oriental Medicine, Pusan

    National University, Yangsan,

    South Korea4Department of Social Work,

    Community and Mental Health,

    Canterbury Christ Church

    University, Kent, UK

    Correspondence to:

    Myeong Soo Lee, Division of

    Standard Research, Korea

    Institute of Oriental Medicine,

    461-24, Jeonmin-dong,

    Yuseong-gu, Daejeon 305-811,

    Korea

    Tel.: + 82 42 868 9266

    Fax: + 82 42 863 9464

    Email: [email protected];

    [email protected]

    Disclosure

    None.

    Linked Comment: Samuels. Int J Clin Pract 2009; 63: 15535.

    META-ANALYS IS

    2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 162216331622 doi: 10.1111/j.1742-1241.2009.02167.x

  • Methods

    Data sourcesThe following electronic databases were searched from

    inception up to May 2009: Medline, AMED, British

    Nursing Index, CINAHL, EMBASE, PsycInfo, The

    Cochrane Library 2009 (Issue 2), six Korean Medical

    Databases (Korean Studies Information, DBPIA,

    Korea Institute of Science and Technology Informa-

    tion, Research Information Centre for Health Data-

    base, Korean Medline, and Korean National Assembly

    Library), four Chinese Medical Databases (China

    Academic Journal, Century Journal Project, China

    Doctor Master Dissertation Full Text DB, andChina Proceedings Conference Full Text DB) and

    three Japanese Medical Databases. The search terms

    used were acupuncture AND schizophrenia. We also

    manually searched our departmental files and relevant

    journal [Focus on Alternative and Complementary

    Therapies (FACT) and Forschende Komplementar-

    medizin und Klassische Naturheilkunde (Research in

    Complementary and Classical Natural Medicine) up

    to May 2009]. In addition, the references in all located

    articles were manually searched for further relevant

    articles.

    Study selectionAll articles were included that reported an RCT in

    which human patients with schizophrenia were

    treated with needle acupuncture with or without elec-

    trical stimulation. Trials were included if they

    employed acupuncture as the sole treatment or as an

    adjunct to other treatments (if the control group also

    received the same concomitant treatment as the

    acupuncture group). Trials testing other forms of

    acupuncture, such as laser acupuncture or moxibus-

    tion were included. Those comparing two different

    forms of acupuncture and those in which no clinical

    data were reported were excluded. Any trials with

    acupuncture as a part of a complex intervention were

    also excluded. No language restrictions were also

    imposed. Dissertations and abstracts were included.

    Data extraction and assessment of risk of biasHard copies of all articles were obtained and read in

    full. All articles were read by two independent review-

    ers (MSL, BCS), and data from the articles were vali-

    dated and extracted according to predefined criteria.

    Risk of bias was assessed using the Cochrane classi-

    fication in four criteria: randomisation, blinding,

    withdrawals and allocation concealment (10). Consid-

    ering that it is very hard to blind therapists to the use

    of acupuncture, we assessed patient and assessor

    blinding separately. Discrepancies were resolved

    through discussions between two reviewers (MSL,

    BCS) and if needed, by seeking the opinion of a third

    reviewer (EE). There were no disagreements between

    the three reviews about the assessment of risk of bias.

    Data synthesisTo summarise the effects of acupuncture on

    outcomes (response rate), we abstracted the risk

    estimates (relative risk: RR) and weighted mean

    differences (WMD), and 95% confidence interval

    (CI) was calculated using the Cochrane Collabora-

    tions software [Review Manager (RevMan) Version

    5.0 for Windows; The Nordic Cochrane Centre,

    Copenhagen, Denmark]. For studies with insufficient

    information, we contacted the primary authors to

    acquire and verify data wherever possible. The vari-

    ance of the change was imputed using a correlation

    factor of 0.4 as suggested by the Cochrane Collabora-

    tion. If appropriate, we then pooled the data across

    studies using random effects models (if excessive

    statistical heterogeneity did not exist). The v2 test, s2

    and the Higgins I2 test were used to assess hetero-

    geneity (11).

    Results

    Study descriptionThe searches identified 87 potentially relevant articles,

    of which 13 met our inclusion criteria (Figure 1). All

    of the included RCTs originated from China. The key

    data are summarised in Table 1 (1223). Manual acu-

    puncture alone was used in four trials (13,14,16) [one

    (13) of them included two different studies], electro-

    acupuncture (EA) was employed in seven trials

    (12,15,1721) and laser acupuncture was used in two

    trials (22,23). A placebo procedure was employed in

    three trials (12,22,23) and conventional pharmacolog-

    ical drug therapy in 10 trials (1321). Seven of the

    included trials adopted a two-arm parallel group

    design (12,1621), three adopted a three-arm parallel

    group design (14,22,23) and three a four-arm parallel

    group design (13,15). Eight trials adopted the princi-

    ples of Chinese Classification of Metal Disorders

    (CCMD) second edition revision (13,14,17) or third

    edition (16,1921), descriptive definitions of which

    were based on the clinical description and diagnostic

    guideline of ICD 10 and DSM-IV (24), for diagnosis

    of Schizophrenia, and another three studies diagnosed

    Schizophrenia according to DSM-III (18,23) and

    DSM-IV (12). The other RCTs did not mention the

    diagnostic methods employed (15,22). Subjects with

    type II (negative) schizophrenia, which was described

    as clinical poverty syndrome involving social with-

    drawal, poverty of content and production of thought

    and speech (2527), were included in four RCTs

    (13,16,19,21), type I (positive) as characterised by

    Acupuncture for schizophrenia 1623

    2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 16221633

  • hallucinations, delusions and formal thought disorder

    (2527), in one RCT (13), paranoid type in two stud-

    ies (22,23), hebetic type in one trial (14), all types in

    two RCTs (15,20). The other two studies did not

    report details about it (17,18). Most of the included

    studies used response rate for each intervention and

    it was generally divided into four categories including

    (1) recovery, (2) marked improvement, (3) improve-

    ment (4) and no change by practitioners. Table 2

    shows the summary of treatment acupuncture points

    and other information related with acupuncture. The

    rationale for the point selection as stated was made

    according to Traditional Chinese Medicine theory

    (13,14,1621,23), classic book (15,17), previous

    reports (12,22) or their clinical experience (12,14,19).

    Assessment of risk of biasThe included trials had high risk of bias except one

    recent RCT (12). Four RCTs described the methods of

    randomisation (12,14,20,21). In three (12,14,20) of

    them, the method was appropriate, whilst in the

    fourth trial it was not (21). Details of drop-outs or

    withdrawals were described in two trials (12,21). One

    RCT (12) reported details about allocation conceal-

    ment and ethical approval from Institutional Review

    Board, whilst the others failed to do so. Three RCTs

    adopted subject blinding (12,22,23) and three RCTs

    employed assessor blinding (12,16,18). Adverse events

    were mentioned in nine studies (1214,1823).

    Outcomes

    Acupuncture plus risoperidone vs. shamacupuncture plus risoperidoneOne RCT (12) tested EA plus risoperidone on Psy-

    chotic Symptom Rating Scales Auditory Hallucina-

    tion Subscale (PSYRATS-AH) and Positive and

    Negative Symptom Scale (PANSS) compared with

    Figure 1 Flow chart of trial selection process

    1624 Acupuncture for schizophrenia

    2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 16221633

  • Tab

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    Sum

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    109

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